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3 



Property of the 

Lancaster City and County 
Medical Society 



No 



m3 



THE 



AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M. I). , 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS | MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION ; OF THE AMERICAN PHILOSOPHICAL SOCIETY J OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA J ASSOCIATE FELLOW 
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES, 
&C. &C. &C. 



NEW SERIES. 
VOL. XL. 




PHILADELPHIA: 
BLANCHAKD AND LEA. 
1860. 



69466 



Entered according to the Act of Congress, in the year 1860, by 
BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 




PHILADELPHIA: 
COLLINS, PRINTER. 



Med. 



TO READERS AND CORRESPONDENTS. 
The following 1 works have been received : — 

On Obscure Diseases of the Brain and Disorders of the Mind : their Incipient 
Symptoms, Pathology, Diagnosis, Treatment, and Prophvlaxis. By Forbes 
Winslow, M. D., D. C. L. Qxon., &c. &c. London: John Churchill, 1860. 
(From the Author.) 

De l'Alcoolisme. These presentee au concours pour I'agregation (section de 
Medecine et de Medecine Legale) et soutenue a la Faculty de Medecine de Paris. 
Par Y. A. Racle, Medecin des Hopiteux, etc. Paris : J. B. Bailliere et Fils, 
1860. (From the Publishers.) 

De la Circulation du Sang dans les Membres et dans la Tete chez 1'Homme. 
Par J. P. Sucquet, M. D. P., etc. Paris : J. B. Bailliere et Fils, 1860. (From 
the Publishers.) 

De la Galvanisation par Influence Appliquee au Treatment des Deviations 
de la Colonne Yertebrale, des Maladies de la Poitrine, des Abaissements de 
1'TJterus, etc. Par le Docteur J. Seiler. Paris : J. B. Bailliere et Fils, 1860. 
(From the Publishers.) 

Haemorrhoids and Prolapsus of the Rectum : their Pathology and Treatment, 
with especial reference to the application of Nitric Acid. By Henry Smith, 
F. R. C. S., Surgeon to the Westminster General Dispensary, &c. Second edi- 
tion. London : John Churchill, 1860. (From the Author.) 

On the Diseases, Injuries, and Malformations of the Rectum and Anus : with 
remarks on Habitual Constipation. By T. J. Ashton, Surgeon to the Blenheim 
Dispensary, &c. &c. &c. Third edition. London : John Churchill, 1860. (From 
the Author.) 

Exposition of a Method of Preserving Yaccine Lymph Fluid and Active : 
with Hints for the more efficient performance of Public "Vaccination. By Wm. 
Husband, M. D., F. R. C. S. E., &c. &c. London : John Churchill, 1859. (From 
the Author.) 

Notes on the Dispatch of Troops by Sea. By Charles J. Kirwan, Esq.. 
L. R. C. S. J., &c. Calcutta, 1859. (From the Author.) 

The Diseases of the Ear : their Nature, Diagnosis, and Treatment. By Jos. 
Toynbee, F. R. S., Aural Surgeon to, and Lecturer on Aural Surgery at, St. 
Mary's Hospital, &c. &c. &c. With 100 engravings on wood. Philadelphia : 
Blanchard & Lea, 1860. (From the Publishers.) 

On the Diseases, Injuries, and Malformations of the Rectum and Anus : with 
remarks on Habitual Constipation. By T. J. Ashton, Surgeon to the Blenheim 
Dispensary, &c. From the third and enlarged English edition. With illustra- 
tions. Philadelphia : Blanchard & Lea, 1860. (From the Publishers.) 

A Practical Treatise on the Diseases of the Lungs, including the Principles of 
Physical Diagnosis. By Walter Hayle Walshe, M. D., Fellow of the Royal 
Coll. of Phys., &c. A new American, from the third revised and much enlarged 
English edition. Philada. : Blanchard & Lea, 1860. (From the Publishers.) 

Clinical Lectures on the Diseases of Women and Children. By Gunning S. 
Bedford, M. D. Sixth edition, carefully revised and enlarged. New York : 
S. S. & W. Wood, 1860. (From the Publishers.) 

An Epitome of Braithwaite's Retrospect of Practical Medicine and Surgery, 
in five parts. By Walter S. Wells. Parts II. III. New York : Charles T. 
Evans, 1860. (From the Publisher.) 

The Institutes of Medicine. By Martyn Paine, A. B., M. D., LL. D., &c. 
Fifth edition. New York. 1859. (From the Author.) 

Record of Private Practice for the years 1858 and 1859 ; and Mortuary Re- 
cord of the City of Troy, N. Y., for the years 1858 and 1859. By Thomas C. 
Brinsmade, M. D., of Troy. Albany, 1860. (From the Author.) 

Food for Babes ; or Artificial Human Milk, and the manner of preparing it 
and administering it to Young Children. By William Henry Cumming, M. D. 
New York : A. D. F. Randolph, 1860. 



8 



TO READERS AND CORRESPONDENTS. 



Urethro-Vaginal, Vesicovaginal, and Recto- Vaginal Fistules : General Re- 
marks ; Report of Cases treated with the Button Suture in this Country, and 
in London, Edinburgh, Glasgow, and Parisian Hospitals. By Nathan Boze- 
man, M. D., of New Orleans. New Orleans, 1860. (From the Author.) 

Dr. Wells the Discoverer of Anaesthesia. New York, 1860. (From Mrs. 
Elizabeth Wells.) 

A Concise Description of the Anatomy of the Fifth Pair of Nerves : being a 
key to the plate on that subject by Henry A. Daniels, M. D. Philadelphia : 
Jones & White, 1860. (From the Publishers.) 

Dental Anomalies and their Influence upon the Production of Diseases of the 
Maxillary Bones. By Am. Forget, M. D., C. L. D., &c. Memoir crowned by 
the Acad. Sciences, Paris, Victor Masson, translated from the French. Phila- 
delphia : Jones & White, 1860. (From the Publishers.) 

Proceedings of the Academy of Natural Sciences of Philadelphia. February, 
March, April, May, 1860. 

Quarterly Summary of the Transactions of the College of Physicians of Phila- 
delphia, from March 2, 1859, to Feb. 1, 1860, inclusive. Philadelphia, 1860. 

Transactions of the Medical Society of the State of New York, for the year 
1860. Albany, 1860. (From Dr. Geo. W. Bradford.) 

Proceedings of the General Meeting of the Medical Profession, in relation to 
the death of Charles Frick, M. D., and Berwick B. Smith, M. D., held Thursday, 
March 29, 1860. Baltimore, 1860. 

Abstract of a Lecture introductory to a Course on Sanitary Science, now in 
process of delivery at the Cooper Institute. By E. Y. Roberts, Esq. New 
York, 1860. 

Biographical Notice of Henry Bond, M. D. Read before the College of Phy- 
sicians of Philadelphia, April, 1860. By D. F. Condie, M. D. Philada., 1860. 

Address to the Graduates of the Medical Department of Pennsylvania Col- 
lege. By Wm. H. Gobrecht, M. D., Professor of Anatomy. Published by the 
Class. Philadelphia, 1860. 

Report of the Pennsylvania Hospital for the Insane, for the year 1859. By 
Thos. S. Kirkbride. M. D., Phys. to the Inst. Philadelphia, 1860. (From the 
Author.) 

Seventeenth Annual Report of the Managers of the [New York] State 
Lunatic Asylum, made to the Legislature, February 7, 1860. Albany, 1860. 

Annual Report of the Officers of the New Jersey State Lunatic Asylum, at 
Trenton, for the year 1859. Trenton, N. J., 1860. 

Forty-Third Annual Report of the state of the Asylum for the relief of per- 
sons deprived of the use of their reason. Published by direction of the Contri- 
butors. Philadelphia, 1860. (From Dr. Worthington.) 

Report on the importance and economy of Sanitary Measures to Cities. By 
John Bell, M. D., of Philadelphia. New York, 1860. (From T. Smith Ho- 
mans, Secretary to Chamber of Commerce, New York.) 

Seventeenth Report to the Legislature of Massachusetts, relating to the 
Registry and Return of Births, Marriages, and Deaths in the Commonwealth 
of Massachusetts] , for the year ending Dec. 31, 1858. By Oliver Warner, 

ec. Com. Boston, 1859. 

Fifth Annual Report on the Births, Marriages, and Deaths in the City of 
Providence, for the year ending December 31, 1859. By Edwin Snow, M. D., 
City Registrar. Providence, 1860. 

Announcement of Brigham Hall : A Hospital for the Insane. Canandaigua. 
N. Y., 1860. 

Addresses on the occasion of the presentation of the Portrait of George B. 
Wood, M. D., Prof, of Pract. Med. and Clin. Pract. in the Univ. Pennsylvania, 
to the Wistar and Horner Museum, on his retirement from his chair, March 15, 
1860. By J. Campbell Shorb, M. D., on the part of the Class of 1859-60, and 
R. La Roche in reply on behalf of the Board of Trustees. Philadelphia, 1860. 

Medical Commencement of the University of Pennsylvania, held March 15, 
1860. With a Valedictory Address delivered to the Graduates. By Joseph 
Carson, M. D., Prof. Mat. Med. and Pharm. Published by the Class. Phila- 
delphia, 1860. 



TO READERS AND CORRESPONDENTS. 



9 



The Eulogium of Medical Science : An Anniversary Discourse delivered 
before the N. Y. Academy of Med., Nov. 2, 1859. By Wm. C. Roberts, M. D. 
Published by order of the Academy. New York, 1860. (From the Author.) 

The Claims and Position of Physiology : An Anniversary Oration delivered 
before the So. Ca. Med. Ass., February 1, 1860. By J. Dickson Beuns, M.D. 
Charleston, I860. 

The following Journals have been received in exchange : — 

Le Moniteur des Sciences Medicales et Pharmaceutiques. Eedacteur en chef, 
M. H. de Castelnau. April, May, June, 1860. 

Journal de Medecine de Bordeaux. Eedacteur en chef, M. Costes. Feb- 
ruary, March, April, 1860. 

Journal de Physiologie de 1'Homme et des Animaux. Publie sous la direc- 
tion de Docteur E. Brown-Sequard. January, 1860. 

Annales Medico-Psychologiques. Par MM. les Docteurs Baillarger, Cerise 
et Moreatt (de Tours). April, 1860. 

Edinburgh Medical Journal. March, April, May, June, 1860. 

The Medical Times and Gazette. April, May, June, 1860. 

Dublin Medical Press. March, April, May, 1860. 

British Medical J ournal. Edited by Andrew Wynter, M. D. April, May, 
June, 1860. 

The British and Foreign Medico-Chirurgical Review. April, 1860. 
The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D. April, 1860. 

Ophthalmic Hospital Reports. Edited by J. F. Streatfeild. No. X. 1860. 

Glasgow Medical Journal. April, 1860. 

The Indian Annals of Medical Science. July, 1859. 

The British American Journal. Edited by Archibald Hall, M. D. Februarv, 
March, April, May, June, 1860. 

The American Journal of Insanity. Edited by the Medical Officers of the 
New York State Lunatic Asylum. April, 1860. 

The New York Journal of Medicine. May, 1860. 

The North American Medico-Chirurgical Review. Edited by S. D. Gross, 
M. D., T. G. Richardson, M. D., and S. W. Gross, M. D. May, 1860. 

The Maryland and Virginia Medical Journal. Edited by J. B. McCaw, M. D., 
and W. 0. Van Bibber, M. D. May, June, 1860. 

The New Orleans Medical and Surgical Journal. Edited by Bennet Dowler, 
M. D. May, 1860. 

Charleston Medical Journal. Edited by J. Dickson Brtjns, M. D. May, 1860. 
The Medical Journal of North Carolina. Edited by Edward Warren, M. D. 
March, 1860. 

St. Louis Medical and Surgical Journal. Edited by M. L. Linton, M. D., 
and W. M. McPheeters, M. D. March, 1860. 

The New Orleans Medical News and Hospital Gazette. Edited by D. W. 
Brickell, M. D., and E. D. Fenner, M.D. April, May, June, 1860. 

Southern Medical and Surgical Journal. Edited by Henry F. Campbell, 
M. D., and Robert Campbell, M. D. April, May, June, 1860. 

The American Journal of Science and the Arts. Conducted by Profs. B. 
Silliman, B. Silliman, Jr., and J. D. Dana. May, 1860. 

Louisville Monthly Medical News. Edited by S. M. Bemis, M. D., and J. W. 
Benson, M. D. March, April, May, 1860. 

The Cincinnati Lancet and Observer. Edited by E. B. Stevens, M. D., and 
J. A. Murphy, M. D. April, May, June, 1860. 

The Chicago Medical Journal. Edited by D. Brainard, M. D., and E. Ingals, 
M. D. April, May, June, 1860. 

The Nashville Medical Record. Edited by Drs. D. F. Wright, T. L. Mad- 
din, and J. H. Callender. April, May, June, 1860. 

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D., and 
J. M. Hamilton, M. D. March, May, 1860. 

New York Monthly Review. Edited by A. Flint, Jr., M. D., and J. H. 
Douglas, M. D. April, May, 1860. 



10 



TO READERS AND 



CORRESPONDENTS. 



The Chicago Medical Examiner. Edited by N. S. Davis, M. D., and E. A. 
Steele, M. D. April, May, 1860. 

The Peninsular and Independent Medical Journal. Edited by A. B. Palmer. 
M. D., Moses Gunn, M. D., and Mr. F. Stearns. March, 1860. 

The San Francisco Medical Press. Edited by E. S. Cooper, M. D. April, 
1860. 

Cleveland Medical Gazette. Edited by G-. C. E. Weber, M. D., and A. May- 
nard, M. D. March, May, 1860. 

The Cincinnati Medical and Surgical News. Edited by A. H. Baker, M. D. 
April, May, 1860. 

Atlanta Medical and Surgical Journal. Edited by Jos. P. Logan, M. D.. 
and W. F. Westmoreland, M. D. March, April, May, June, 1860. 

Oglethorpe Medical and Surgical Journal. Edited by H. L. Byrd, M. D.. 
and Wm. Hauser, M. D. March, 1860. 

The Dental Cosmos. Edited by J. D. White, M. D., J. H. McQuillen, 
D. D. S., and Geo. J. Ziegler, M. D. April, May, June, 1860. 

The Dental Eegister of the West. Edited by J. Taft and Geo. Watt. April. 
May, June, 1860. 

The Druggist. Edited by C. A. Smith. April, June, 1860. 

The Kansas City Medical and Surgical Eeview. Edited by G. M. B. Maughs. 
M. D., and T. S. Case, M. D. March, 1860. 

The American Journal of Dental Science. Edited by Chapin A. Harris, M. 
D., and A. Snowden Piggot, M. D. April, 1860. 

The American Journal of Pharmacy. Published by authority of the Phila- 
delphia College of Pharmacy. Edited by Wm. Procter, Jr. May 1860. 

American Druggists' Circular, and Chemical Gazette. May, June, 1860. 

The Journal of Materia Medica. Edited by J os. Bates, M. D., and H. A. 
Tilden. April, May, June, 1860. 

The Pacific Medical and Surgical Journal. Edited by Chas. McCormick, 
M. D., and David Wooster, M. I). February, March, April, May, 1860. 

The American Medical Monthly. Edited by J. H. Douglas, M. D., and A. 
Flint, Jr., M. D. April, May, June, 1860. 

The Savannah Journal of Medicine. Edited by Juriah Harriss, M. D., and 
R. D. Arnold, M. D. March, May, 1860. 

The Saint Joseph Journal of Medicine and Surgery. Edited by Drs. Hed- 
dens, Chambers, and Scearce. May, 1860. 

Georgia Medical and Surgical Encyclopaedia. Edited by H. N. Hollifield. 
M. D., and T. W. Newsome, M. D. May, June, 1860. 

The Belmont Medical Journal. Edited by Wm. Estep, M. D., and E. Gaston. 
M. D. March, 1860. 



Communications intended for publication, and Books for Review, should be sent, 
free of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the 
Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed 
as above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent 
Garden, London ; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will 
reach us safely and without delay. We particularly request the attention of our 
foreign correspondents to the above, as we are often subjected to unnecessary ex- 
pense for postage and carriage. 

Private communications to the Editor, may be addressed to his residence, 1525 
Locunt Street. 

All remittances of money, and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Blanchard & Lea. 

Iggf" The advertisement-sheet belongs to the business department of the Journal 
and all communications for it should be made to the publishers. 

To secure insertion, all advertisements should be received by the 20th of the 
previous month. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. LXXIX. NEW SERIES. 
JULY, 1860. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. . 

ART. PAGE 

I. A Statistical Examination of the Operation of Deligation of the Primitive 
Iliac Artery, embracing the Histories (in abstract) of Thirty-two Cases. 

By Stephen Smith, M. D., Surgeon to Bellevue Hospital, New York. . 17 

II. Carcinoma of Uterus : Extirpation. By A. F. Sawyer, M. D., San 
Francisco. . . . . 46 

III. Two Cases of Reducible Inguinal Hernia operated on for the Radical 
Cure. By R. A. Kinloch, M. D., Surgeon of the Roper Hospital, Charles- 
ton, S. C. (With five wood-cuts.) 52 

IV. Extirpation of the Parotid Gland. By David Prince, M. D., Jackson- 
ville, 111. (With two wood-cuts.) 57 

V. Animal Chemistry, and its Relations to Therapeutics. By J. L. Teed, 

M. D., of Mendota, 111 . . .63 

YI. Some Account of Diphtheritis, as it occurred on the Water-shed be- 
tween the Tallahatchie and Mississippi Rivers. By Lea Z. Williamson, 
M. D., Sardis, Mississippi. 99 

VII. On Nervous Action. By John Ashhurst, Jr., M. D., of Philadelphia. 102 

VIII. Case of Oblique Fracture of the Femur treated by the use of Adhe- 
sive Plaster, as a means of producing Extension and Counter-Extension. 

By J. F. Huber, M. D., Lancaster, Pa. . . . . . . .10b 

IX. On the Poisonous Effects resulting from the Employment of Arsenical 
Preparations in the Arts. By M. Carey Lea, Esq. .... 110 

X. Case of Compound Fracture of the Bones of the Tarsus, implicating the 
Ankle-Joint, with perfect Recovery. By Wm. T. Hord, M. D., Passed 
Assistant Surgeon U. S. Navy. ........ 113 

XL Case of Dislocation of the Astragalus, occurring on board U. S. Sloop 
of War Jamestown. By T. L. Williams, M. D. ; Surgeon. . . .114 



12 CONTENTS. 

TRANSACTIONS OF SOCIETIES. 

ART. PAGE 

XII. Summary of the Proceedings of the Pathological Society of Phila- 
delphia. 115 



Perforation of a Pulmonary Yalve. By Dr. Hall 115 

Cancer of the Rectum of exceedingly small size ; enormous accumu- 
lation of Fat in the Abdomen. By Dr. Packard. . . .117 
Slit-like Perforation of the Aortic Yalves. By Dr. Packard. . .119 

Wound of the Stomach. By Dr. Reed 121 

Spontaneous Cure of a Popliteal Aneurism. By Dr. Lenox Hodge. 124 
Extensive Fracture of the Skull ; Life prolonged for four hours. By 

Dr. Reed . .124 

Cases of Diphtheritis. By Dr. Keller . 125 

Fatty Degeneration of the Kidney. By Dr. Livezey. . . . 127 
Hourglass Contraction of the Stomach with Thickening and Con- 
striction of the Pylorus. By Dr. Livezey 128 

Abnormal Position of the Right Kidney ; Dilatation of the Heart. 
By Dr. Packard, for Dr. William R. Dunton 129 



REYIEWS. 

XIII. Therapeutics and Materia Medica : A Systematic Treatise on the 
Action and Uses of Medicinal Agents, including their Description and 
History. By Alfred Stille, M. D., late Professor of the Theory and Prac- 
tice of Medicine in the Medical Department of Pennsylvania College, &c. 
Philadelphia : Blanchard & Lea, 1860. In 2 vols. 8vo. pp. 813, 975. . 131 

XIY. A Practical Treatise on the Diagnosis, Pathology, and Treatment 
of Diseases of the Heart. By Austin Flint, M. D., Professor of Clinical 
Medicine, etc., in the New Orleans School of Medicine ; Yisiting Physi- 
cian to the New Orleans Charity Hospital ; Honorary Member of the 
Medical Society of Yirginia, of the Kentucky State Medical Society, of 
the Medical Society of Rhode Island, of the Pathological Society of Phi- 
ladelphia, etc. Philadelphia : Blanchard & Lea, 1859. pp. 473, 8vo. . 141 

XY. A Medico-Legal Treatise on Malpractice and Medical Evidence, 
comprising the Elements of Medical Jurisprudence. By John J. Elwell, 
M. D., Member of the Cleveland Bar. New York : John S. Yoorhies, 
1860. 8vo. pp. 588 . . .153 

XYI. Clinical Lectures on Certain Acute Diseases. By Robert Bentley 
Todd, M. D., F.R. S., Author of "Lectures on Diseases of the Urinary 
Organs," &c. ; formerly Physician, now Consulting Physician, to King's 
College Hospital, London. Philadelphia : Blanchard & Lea, 1860. 8vo. 
pp. 473. . ... • . 167 

XYII. The Diseases of the Ear ; their Nature, Diagnosis, and Treatment. 
By Joseph Toynbee, F. R. S., Fellow of the Royal College of Surgeons of 
England, etc. etc. Philadelphia : Blanchard & Lea, 1860. 8vo. pp. 440. 181 



CONTENTS. 



1 3 



BIBLIOGRAPHICAL NOTICES. 

ART. PAGE 

XYIII. Reports of American Institutions for the Insane. 

1. Of the New York State Asylum, for 1859. 
• 2. Of the Bloomingdale Asylum, for 1859. 

3. Of the New York City Asylum, for 1859. 

4. Of the New Jersey State Hospital, for 1859. 

5. Of the United States Government Hospital, for the fiscal year 1858-9. 

6. Of the Kentucky Eastern Asylum, for the two fiscal years 1857-8 

and 1858-9. 

7. Of the Kentucky Western Asylum, for the two fiscal years 1857-8 

and 1858-9 t , . . . . .187 

XIX. A Familiar Forensic Yiew of Man and Law. By Robert B. Warden. 
Columbus : Follett, Foster & Co., 1860. 8vo. pp. 550 194 

XX. De l'Hematocele Retro-uterine et des Epanchements Sanguins Non- 
enkystes de la Cavite Peritoneale du petit Bassin, consideres comme 
Accidens de la Menstruation. Par le Docteur Auguste Yoisin, Ancien 
Interne des HGpitaux de Paris, Laureat de la Facuite de Medecine et de 
la Societe de Ckirurgie, Membre de la Societe Anatomique, de la Societe 
Medicale d'Observation, de la Societe de Medecine du Department de la 
Seine. Avec une planche. Paris : J. B. Bailliere et Fils, 1860. Octavo, 
pp. 368. 

Retro-uterine Hematocele and Non-encysted Effusions of Blood in the 
Peritoneal Cavity, considered as Accidents of Menstruation. By Dr. 
Yoisin. With one lithograph plate. . 196 

XXI. Stricture of the Urethra : its Complications and Effects. A Prac- 
tical Treatise on the Nature and Treatment of those Affections. By 
Robert Wade, F. R. C. S., Senior Surgeon to the Westminster General 
Dispensary ; Fellow of the Royal Medical and Chirurgical Society ; and 
late Lecturer on Pathological Anatomy. Fourth edition (with engrav- 
ings), considerably enlarged. London, 1860. 8vo. pp. 354. . . . 198 

XXII. Haemorrhoids and Prolapsus of the Rectum : their Pathology and 
Treatment; with especial reference to the application of Nitric Acid. 
By Henry Smith, F. R. C. S., Surgeon to the Westminster General Dis- 
pensary ; formerly House-Surgeon to King's College Hospital. Second 
edition. London, 1860. 12mo. pp. 108 201 

XXIII. Exposition of a Method of Preserving Yaccine Lymph, fluid and 
active ; with Hints for the more Efficient Performance of Public Yacci- 
nation. By William Husband, M. D., Fellow of the Royal College of 
Surgeons of Edinburgh, and one of the Medical Officers of the Royal 
Public Dispensary and Yaccine Institution, Edinburgh. London, 1860. 
12mo. pp. 46 202 

XXI Y. On the Organs of Yision, their Anatomy and Physiology. By 
Thomas Nuneley, F. R. C. S. E., Lecturer on Surgery in the Leeds School 
of Medicine, Senior Surgeon to the Leeds General Eye and Ear Infirm- 
ary, etc. etc. London : John Churchill, 1858. 8vo. pp. 373. . . 205 

XXY. The Pathology and Treatment of Yenereal Diseases, comprising the 
most recent Doctrines on the subject. By John Harrison, F. R. C.S. 
London, 1860. Octavo, pp. 176. . 206 

XXYI. Description des Eaux Minero-Thermales et des Etuves de 1'Ile 
d'Ischia, etc. Par J. E. Che valley de Rivaz, Docteur en Medecine des 
Facultes de Paris et de Naples, etc. etc. etc. Sixieme edition, Revue, 
Corrigee et Augmentee. Naples, 1859. 8vo. pp. 214. 

Description of the Thermal Mineral Springs and Natural Yap our Baths of 
the Island of Ischia, etc. etc. etc. By J. E. Chevalley de Rivaz, M. D., 
of Paris and Naples. Sixth edition, revised and enlarged. . . . 207 



u 



CONTENTS. 



ART. * PAGE 

XXVII. De 1'Alcoolisme. These presentee an concours pour l'agrega- 
tion (section de M6decine et de Medecine Legale) et soutenue a la 
Faculte de Medecine de Paris. Par V. A. Eacle, Medecin des H6pitaux, 
etc. Paris : J. B. Bailliere et Fils, 1860. pp. 122. 

On Alcoholism . . .209 

XXVIII. A Treatise on Medical Electricity, Theoretical and Practical, and 
its Use in the Treatment of Paralysis, Neuralgia, and other Diseases. By 

J. Althaus, M.D. Philadelphia: Lindsay & Blakiston, 1860. pp. 354. . 210 

XXIX. Proceedings of the American Pharmaceutical Association, at the 
Eighth Annual Meeting, held in Boston, Mass., September, 1859, with 
the Constitution and Roll of Members. Boston : Press of Geo. C. Rand 

& Avery, 3 Cornhill, 1859 . . . .212 

XXX. Food for Babes ; or Artificial Human Milk, and the Manner of 
Preparing it and Administering it to Young Children. By Win. Henry 
Gumming, M. D. New York : Anson D. F. Randolph, 1859. 12mo. 

pp. 100 214 

XXXI. The Institutes of Medicine. By Martyn Paine, M. D., Professor 
of the Institutes of Medicine and Materia Medica in the University of 
the City of New York, etc. etc. Fifth edition. New York : Harper & 
Brothers, 1859. 8vo. pp. 1109 216 



QUAKTEKLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 
Anatomy and Physiology. 



page 

1. Observations on Digestion, made 
on a Case of Fistulous Opening 
into the Small Intestine. By 
Prof. Busch. . . . .217 



PAGE 

2. Structure of the Cerebro-spinal 
Capillaries. By M. C. Robin. . 221 

3. Experimental Inquiry into the 
Action of Alcohol on the Nerv- 
ous System. By Dr. \V~. Marcet. 222 



Materia Medica and Pharmacy. 



4. New Application of Chloroform 
in Neuralgia and in certain Rheu- 
matic Complaints. By Mr. Little. 222 



5. Cypress as a Remedy for Bruises. 
By Dr. Little. . . . . 223 



Medical Pathology and Therapeutics, and Practical Medicine. 



6. Treatment of Phthisis by Cod- 
liver Oil and Uva Ursi. By Dr. 
Henry Kennedy. . . . 224 

7. Treatment of Phthisis by the 
Hypophosphites of Soda and of 
Lime. By Dr. Richard Quain. . 227 



8. Rheumatism treated by the Hy- 
podermic Injection of Atropia. 

By Dr. Cowdell. . . .228 

9. Successful Treatment of Hoop- 
ing-Oough, by increasing Doses 
of Sulphate of Zinc and Extract 

of Belladonna. By Dr. Fuller. . 229 



CONTENTS. 



15 



10. Nitrate of Silver in Diphtheria. 

By Dr. Hauner. . . .230 

11. On the Comparative Results 
of the Treatment of Croup by 
Tracheotomy and by Medication, 
during the years 1854-58. By 
Dr. Barthez 231 

12. Bloodletting in Disease. By 
Dr. Markham 233 

13. Clinical Experience in Pneu- 
monia. By Dr. Gairdner. . .234 

14. Typhus and Typhoid Fevers as 
seen in Dublin. By Dr. Henry 
Kennedy 237 



PAGE 

15. Diseased Supra-renal Capsules 
unconnected with Bronzed Skin. 

By E. Crossman, Esq. . . 239 

16. Contributions to the Pathology 
of Diabetes Mellitus. By Rud. 
Leubuscher 239 

17. Diagnosis of Phthisis by the 
Microscope. By Dr. F. J. Brown. 240 

18. Condition of the Blood in Ma- 
nia. By Dr. W. C. Hood. . 242 

19. Abscess in the Iliac Fossa in 
Children. By M. Bouchut. . 242 



Surgical Pathology and Therapeutics, and Operative Surgery. 



20. Treatment of Axillary Aneu- 
rism. By Mr. Syme. . . 243 

21. New Method of Effecting the 
Radical Cure of Hernia. By 
Mr. John Wood. . . .244 

22. Mammary Inflammation and 
Mammary Abscess. By Dr. Mc- 
Clintock '.247 

23. Injection of Iodine info the 
Peritoneum. By M. Boinet. . 251 

24. Communicability of Secondary 
Syphilis. ByMr.Weeden Cooke. 252 



25. Condition of the Prostate in 
Old Age. By Dr. J. C. Messer. 

26. Enlarged Prostate. By Dr. 
Maclachlan 

27. Tubercle of Bone. By Dr. 
Echeverria 

28. Results of Amputations ob- 
served at Constantinople during 
the Crimean War. By M. Sal- 
leron. ' 255 



252 



255 



255 



Ophthalmology. 



29. Synthesis of Cataract. By Dr. 
Richardson 257 

30. Dislocation of the Lens, the 



Effect of Vomiting eight days 
after Keratonyxis. By Mr. White 
Cooper 259 



Midwifery. 



31. On the Use of the Forceps in 
Face Presentations. By Dr. Yon 
Helly 260 

32. Experience in Face Presenta- 
tions. By Dr. Spaeth. . . 262 

33. Observations on External Turn- 
ing. By Prof. Carl Esterle. . 263 

34. Cases of Prolapsus of the 
Membranes in Labour. By Drs. 
Leopold and Crede. . . . 264 

35. Twin Births. Dr. E. Yon Sie- 
bold 264 

36. On Special Position and the 
Obstetric Binder as Aids in the 



Treatment of Impeded Parturi- 
tion. By Mr. Robert Hardey. . 265 

37. Ruptured Perineum. By Mr. 

I. B. Brown 266 

38. Puerperal Convulsions success- 
fully treated by Subcutaneous 
Injections of Morphia. By Prof. 
Scanzoni 266 

39. Morning Sickness; its signifi- 
cance as a symptom. By Dr. 

T. Inman 268 

40. Pepsine in Yomiting of Preg- 
nancy. By M. Corvisart. . . 270 

41. Foetal Auscultation. By Dr. 
Francis Adams. . . . 270 



Medical Jurisprudence and Toxicology. 



42. On the Closure of the Anterior 
Fontanelle. By M. Roger. . 271 

43. On the Linse Albicantes in 
Puerperal Women. By Dr. 
Crede 271 

44. Condition of the Lungs after 



Death from Chloroform. By M. 

Faure 272 

45. Detection of Arsenic, Anti- 
mony, Copper, and Bismuth, by 
Electrolysis. By Prof. Bloxam. 273 



16 



CONTENTS. 



AMERICAN INTELLIGENCE. 
Original Communications. 



PAGE 

Case of Puerperal Convulsions 
from Albuminuria, in which 
Chloroform, was successfully- 
used, with Remarks. By Chas. 
A. Lee, M.D. of Peekskill, N. Y. 275 

Case of Poisoning by Strychnia ; 

Domestic 

Fistulous Ulcer in front of the 
Larynx. By Dr. John Watson. 279 

Traumatic Tetanus treated by 
Large Doses of Cannabis Indica. 
By Dr. Chas. O'Donovan. . . 280 

Traumatic Tetanus successfully 
treated by Large Doses of Cam- 
phor and Opium. By Dr. W. C. 
Yan Bibber 281 

Chloroform in the Chill of Conges- 
tive Fever. By Dr. J. E. Keator. 282 

Caffeine as an Antidote to the 
Poisonous Narcotism of Opium. 
By Dr. H. F. Campbell. . . 282 

Apparatus for Transverse Frac- 
ture of the Patella. Bv Dr. S. 
T. Knight. . .284 



PAGE 

Use of Chloroform. By J. R. 

Smith 278 

Treatment of Pneumonia. By L. 

M. Lawson, M.D. . . . 279 
Rhubarb in Suppurating Burns. 

By Dr. Samuel R. Rittenhouse. 279 

Summary. 

Ligation of External Iliac Artery. 
By Dr. Reugnet. . . .284 

Paralysis consequent upon the 
Poison of Diphtheria. By Dr. 
Jas. B. Reynolds. . '. . 285 

Addison's Disease. By Dr. Ed- 
ward B. Dalton. . . .285 

Foetus carried Twenty-two Months 
beyond Term. By Dr. James 
M. Buzzell 286 

Alarming Symptoms caused by the 
Displacement of Artificial Teeth 
during Etherization. By Dr. J. 
Mason Warren. . . .287 

Anaesthesia and Anaesthetics. By 
Dr. Edward R. Squibb. . . 287 



THE 



AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY 1 8 6 0. 



Art. L — A Statistical Examination of the Operation of Deligation of 
the Primitive Iliac Artery, embracing the Histories {in abstract) of 
Thirty-two Cases. By Stephen Smith, M. D., Surgeon to Belle vue 
Hospital, New York. 

The operation of applying a ligature to the primitive iliac artery has 
justly been considered one of the most important in operative surgery. 
The rank which this operation takes is not due to the difficulty which 
attends its execution, but to the dangers which threaten the extremity thus 
suddenly deprived of its source of nourishment. In this respect the ligation 
of the primitive iliac artery differs materially from the same operation on 
the other principal arterial trunks. A ligature placed on the common 
carotid deprives the head of only one-half of its supply of arterial blood ; 
ligature of the subclavian artery, except in the first part of its course, or 
the femoral or external iliac, leaves important anastomosing branches to 
sustain in a certain degree the temporarily interrupted supply, and establish 
readily a sufficient collateral circulation. But when a ligature is applied 
to the common trunk of the vessels which supply the lower extremity with 
blood, we should reason a priori that the limb thus suddenly deprived of 
its nutrition must perish long before the feeble collateral circulation could 
be sufficiently established to afford the requisite support. And again, the 
aphorism that the success of the operation of securing arteries diminishes 
as we approach the great centre of the circulation applies with especial 
force to this operation ; this is seen when we compare the same operation 
upon the external iliac artery and the common trunk, the mortality sud- 
denly increasing from about twenty-eight per cent, in the former to seventy- 
seven per cent, in the latter. 

No. LXXIX.— July 1860. 2 



18 Smith, Deligation of the Primitive Hiac Artery. [July 

The literature of the operation of the ligation of the primitive iliac artery, 
considered in a purely scientific light, is confined to the last third of a 
century. The operation of Gibson, in 1812, was one of those accidental 
occurrences in which the operator resorted to the only remaining expedient 
to save his patient, quite regardless of the nature of his operation, the 
manner of executing it, or the consequences which might follow. Never- 
theless, it was a bold and daring operation, and must forever entitle the 
operator to the honour of first applying a ligature to this important arterial 
trunk. The procedure which Gibson was compelled to adopt, owing to 
the nature of the injury, and the fatal issue of his case, failed to demon- 
strate the feasibility and practical value of the operation, and nearly fifteen 
years elapsed before it was again attempted. The operation of Mott, in 
1827, for aneurism of the external iliac artery, was not only the first of the 
kind for this disease, but it was the first which had ever been deliberately 
planned and executed. It had also the additional interest of being the first 
successful case. A new era now began in the history of this important 
operation, and during the thirty-three years that have since elapsed it has 
been performed in at least thirty-one instances, averaging nearly one case 
annually. And it is an interesting fact to notice in this connection that 
Mott's patient still lives, standing as a living monument of the skill and 
success of this eminent surgeon. 

Having recently had occasion to apply a ligature to the primitive iliac 
artery for aneurism of the external iliac, my attention has been particularly 
called to the history of this operation. The materials for this historical 
resume are widely scattered through the medical periodicals, no very com- 
plete collection having yet been made of the recorded cases, and it is on 
this account that our most reliable surgical authorities entertain such erro- 
neous impressions of the general success of this operation. I have endea- 
voured, as far as my means of consulting medical periodicals would permit, to 
supply to the literature of the ligation of arteries, the history of this opera- 
tion upon the common iliac, by a collection of the recorded cases, and their 
proper collation for study and reference. The cases are given in abstract ;. 
but still, it is believed, with sufficient detail for the proper appreciation of 
the interesting features of each case, and the grouping of them in classes 
will enable the reader to arrive at general conclusions of practical value. 

This collection comprises thirty-two cases, occurring, according to the 
residence of the surgeons, as follows : In the United States, 15 ; England, 5 ; 
Ireland, 1 ; Scotland, 4 ; South America, 2 ; France, 2 ; Germany, 1 ; Rus- 
sia, 2. There are occasional references by authors to other cases, of which, 
however, I have not been able to obtain any details. Guthrie states ( Com- 
mentaries, &c, sixth edition) that he has twice tied the common iliac with 
success ; and although he frequently alludes to the subject in his lectures 
and writings, the only case he adduces is the one of which an abstract is 
herein given. Altmuller, of Germany, is reported to have performed the 



I860.] 



Smith, Deligation of the Primitive Iliac Artery. 



19 



operation : but Professor TJhde, in his tables of cases of obligation of the 
common and the internal iliac arteries {Deutsche Klinik), places his case 
in the latter collection. According to Linhart (Gompend. der Ghirurgisch. 
Operationslehre, Wien, 1856, p. 93), Dumreicher has once performed this 
operation ; but he gives only the method of operating. 

The following table, in which the cases in this collection are arranged in 
chronological order, with the results, will be found convenient for refer- 
ence : — 



No. 


Date of operation. 


Operator. 


Result. 


1 


July 


27, 1812 


Gibson, oi Philadelphia 


Died 


z 


March. 


15, 1827 


Mott, oi INew York .... 


Cured 


3 


July 


18, 1828 


Crampton, of Dublin . 


Died 


4 


December 


1, 1829 


Listen, of Edinburgh .... 


Died 





August 


24, 1833 


Guthrie, of London .... 
Stevens, of New York .... 


Cured 





April, 


1836 


Died 


7 


May 


26, 1837 


Salomon, of St. Petersburgh . 


Cured 


8 




1837 


Garviso, of Monte Video . 


Died 


n 


June 


8, 1838 


Syme, of Edinburgh .... 


Died 


IU 


November 29, 1838 


Pirogoff, of Dorpat 


Died 


11 


April 


10, 1839 


Bushe, of New York .... 


Died 


12 


February 


22, 1840 


Deguise, of Paris 


Cured 


lo 


August 


26, 1840 


irubu, Ui ixcw xoiJS. .... 


JJied 


14 


August 


29, 1842 


Peace, of Philadelphia .... 


Cured 


15 


December 


3, 1843 


Hey, of York ..... 


Cured 


16 




1843 


Grarviso, of Monte Video 


Cured 


17 


January 


27, 1845 


Stanley, of London .... 


Died 


18 


June 


3, 1847 


Lyon, of Glasgow ..... 


Died 


19 


September 19, 1850 


Chassaignae, of Paris .... 


Died 


20 


December 


29, 1851 


Jones, of Liverpool .... 


Died 


21 


January, 


1852 


Moore, of London ..... 


Died 


22 


March. 


27, 1852 


Wedderburn, of New Orleans 


Died 


23 


October 


7, 1852 


Uhde, of Braunschweig 


Died 


24 


November 


1853 


Van Buren, of New York 


Died 


25 


March 


20, 1157 


Edwards, of Edinburgh 


Died 


26 


March 


26, 1857 


Holt, of Georgia ..... 


Died 


27 


July 


15, 1857 


Meier, of New York .... 


Died 


28 


July 


3, 1858 


Parker, of New York .... 


Died 


29 


July 


6, 1858 


Buck, of New York .... 


Died 


30 


October 


6, 1858 


Stephen Smith, of New York 


Died 


31 


January 


26, 1859 


Stone, of New Orleans .... 


Died 


32 




Goldsmith, Louisville .... 


Died 



The indications which have thus far led to the deligation of the primitive 
iliac artery may be divided as follows : — 

1. For the arrest of hemorrhage. 

2. For the cure of aneurisms. 

3. For the cure of pulsating tumours, which proved to be malignant 

growths. 

4. For the prevention of hemorrhage in the removal of a morbid growth. 

These divisions I have endeavoured to preserve, although it will appear 
that in the great majority of cases an aneurism led directly or remotely to 
the operation. 



20 



Smith, Deligation of the Primitive Iliac Artery. [July 



Group I. Reports of Eleven Cases in which the Primitive Iliac Artery 
was Ligated for the Arrest of Hemorrhage. 

Case 1. Gunshot wound of the left common iliac artery; ligature of 
that vessel ; secondary hemorrhage ; death on the fifteenth day. By Wm. 
Gibson, M. D., Professor of Surgery in the University of Pennsylvania. 
{American Medical Recorder, vol. iii.) 

History. — The patient was a male, get. 38 ; received a wound from a 
musket-ball, which entered the left side of the abdomen, passed through the 
intestines, and, opening the common iliac artery, lodged in the sacrum. 

Operation. — The operation was performed July 2t, 1812, as follows : 
The external wound was opened to the extent of seven inches, the perito- 
neum cut through, the intestines turned to one side, and the ligature passed 
with a common probe ; a ligature was also passed around the lower 
extremity. 

Progress. — The limb below the knee was cold and insensible for several 
days ; symptoms of peritonitis soon appeared ; severe hemorrhage occurred 
from the wound on the ninth day, which recurred until the fifteenth day, 
when death took place. 

Autopsy. — Evidences of severe peritonitis ; the upper ligature had sepa- 
rated, but there was no closure of the artery ; lower ligature still applied. 

Case 2. Necrosis of femur ; amputation just below trochanter minor; 
secondary hemorrhage; ligature of common iliac artery; death in twenty- 
four hours. By Robert Liston, Esq. {London Med. Gaz., April 24, 
1830.) 

History. — The patient was a lad, est. 8, greatly reduced by necrosis of 
the femur of one year's standing ; amputation of the leg was performed 
immediately below the trochanter minor by the anterior and posterior flap 
method ; on the seventh day after the operation hemorrhage occurred from 
the stump and could not be arrested, and ligature of the common iliac was 
determined upon. 

Operation. — Incision commenced about an inch above the anterior supe- 
rior spine of the ilium, two inches toward the mesial line, and continued for 
upward of three inches to the internal ring; no accident occurred. 

Progress. — Vomiting soon after occurred ; great depression followed ; 
transfusion of blood was performed with slight relief ; sank and died twenty- 
four hours after the operation. 

Autopsy. — Ligature found applied to common iliac, half an inch above 
its bifurcation, surrounded by effused lymph. 

Case 3. Aneurism of the external iliac artery; formation and sepa- 
ration of a slough; profuse hemorrhage ; ligature of the common iliac ; 
death. By Dr. Guatano Garviso, of Monte Yideo, South America. 
(Annal. de la Chirurgie, November, 1844; and Journ. de Chirurgie, 
1846.) 

History. — An aneurism of the external iliac artery, size of an adult's 
head, and extending from the pubis to the umbilicus ; an eschar had formed 
on the tumour, which began to separate and gave rise to abundant hemor- 
rhage immediately previous to the operation. 

Operation. — Incision four inches in length from below upwards and 
from without inwards, dividing the skin, the muscles, and the peritoneum ; 
pushed upwards the intestines and omentum; the vessel being found, its 
peritoneal covering was opened, and a ligature applied to the artery. 

Progress. — Patient died in four hours. 



I860.] 



Smith, Deligation of the Primitive Iliac Artery. 



21 



Case 4. Aneurism of the right external iliac artery; ligature of that 
artery; secondary hemorrhage ; ligature of the common iliac ; gangrene 
of the wound; death. By Dr. Nicolaus Pirogoff, Prof, der Chirurgie, 
&c, Annalen der Chirurgischen Abtheilung des Clinicum der kaiser- 
lichen Universitat Dorpat, 1839, and Fricke u. Oppenheim Zeitsch., xiii. 
Hamburg, 1840, p. 247. 

History. — Patient was a man, set. , on whom the operation of 

ligaturing the external iliac artery for aneurism of that artery had been 
undertaken with Graefe's ligature staff ; this instrument somewhat resem- 
bles the common polypus canula, and when the ligature is applied it is 
tightened gradually by a screw, to which the free ends of the thread are 
fastened ; a ligature had been passed around the external iliac, and com- 
pression was thus kept up for five days, when the dressings were changed, 
and the ligature and canula removed from the artery ; suppuration was free 
and the wound healthy, except some dead cellular tissue which adhered to 
the thread ; no pulsation of the tumour occurred after the removal of the 
ligature ; scarcely were new dressings applied with adhesive plaster when 
arterial blood was noticed escaping through them ; they were instantly 
removed, when a profuse hemorrhage occurred ; this was restrained by 
pressure, when the only alternative left to the operator was the application 
of a ligature higher up, either upon the external iliac or the common 
trunk. 

Operation. — Incision thfee fingers' breadth above the former ; perito- 
neum lacerated at two points, owing to firm adhesions which had been 
formed. 

Progress. — On the following day symptoms very favourable ; on the 
sixth day the edges of the second wound were found separated, the surface 
of the wound appeared of a dirty-gray, and some ichorous discharge was 
noticed ; no remedies were prescribed for the next five days, although the 
gangrene continued to extend ; on the twelfth fecal matter began to escape 
from the wound, and patient had a chill ; on the fifteenth day hemorrhage 
of arterial blood occurred, and on the sixteenth day he died. 

Autopsy. — Common iliac artery completely severed by the ligature ; the 
upper portion contained a coagulum of blood and lymph adherent to the 
inner coat, but indicating by a thrombus at the end of the artery the seat 
of the recent hemorrhage ; the lower portion was surrounded by a loose 
coagulum, in which lay the ligature quite loose; between the two points 
of ligature a portion of artery was found isolated ; the first ligature, ap- 
plied to the external iliac, had also divided the artery, and the lower portion 
was filled with a coagulum. 

Case 5. Aneurism of the right external iliac artery; ligature of that 
artery and oozing of blood from the wound after its application; ligation 
of the primitive iliac, and the femoral artery immediately below thepubes; 
recovery. By M. Degtjise, of Paris. {Gazette Medicate, May, 1840, and 
American Journal of the Medical Sciences, October, 1841.) 

History. — Patient, a man, set. 42, carpenter ; a month before, he was 
suddenly seized with a pain in the right groin ; on examination a tumour 
was found in the right iliac fossa, above the femoral arch, size of a hen's 
egg, pulsating, and having all the characters of an aneurism ; diagnosis, 
aneurism of the external iliac ; treatment, deligation of the external iliac. 

Operation. — Incision began at the anterior superior spine of the ilium 
and terminated at the external side of the inguinal ring ; in the dissection 



22 Smith, Deligation of the Primitive Iliac Artery. [July 

the tumour was accidentally opened and free hemorrhage occurred ; a liga- 
ture was placed upon the external iliac, but this vessel gave way under the 
ligature, and the operator at once tied the primitive iliac ; a ligature was 
also applied to the femoral below the pubes ; in this latter operation the 
femoral vein was also opened. 

Progress. — Temperature and sensibility of limb natural ; ligature on the 
vein separated on the fifth day, that on the common trunk on the sixteenth, 
and that on the external iliac on the eighteenth ; wound completely healed 
in five weeks, and patient discharged. 

Case 6. Aneurism of left external iliac artery; ligature of the com- 
mon iliac ; death. By Alfred C. Post, M. P., Surgeon to the New York 
Hospital. (New York Journal of Medicine and Surgery, vol. iii.) 

History. — Patient, a man, set. 20, blacksmith; had syphilis recently; 
nine months before observation noticed a small circumscribed tumour, size 
of a filbert, in the left iliac region, with marked pulsation ; this swelling 
was treated as a bubo ; subsequently the tumour enlarged rapidly after a 
long walk, with great pain and cramps in leg ; it was then leeched. On 
examination, a pulsating tumour was found in the left iliac region, remark- 
ably flat, hard, and incompressible ; bellows murmur distinct ; diagnosis, 
not aneurismal ; leeches and poultices applied ; fluctuation being detected, 
an opening was made by free incision, and finger introduced, which deter- 
mined its aneurismal character ; hemorrhage followed, although wound was 
filled. 

Operation. — Tumour extended so high as to make it necessary to open 
the peritoneal cavity; incision vertical, about six inches in length, through 
abdominal parietes ; opened the peritoneum. 

Progress. — Pulsation ceased ; pain continued severely in the limb ; sto- 
mach soon became irritable, with vomiting ; died twenty -four hours after 
the operation ; no autopsy. 

Case t. Aneurism of the left gluteal artery; rupture of the internal 
iliac in an attempt to ligate it; ligature of the common iliac ; death. 
By Prof. C. W. E. IJhde, of Braunschweig. (Deutsche Klinik, No. 16, 
April, 1853.) 

History. — Patient, a man, set. 26 ; a coppersmith by trade; healthy; had 
rheumatism some five years before in leg ; fourteen days before felt severe 
pain in the left hip, which was attributable partly to a blow upon the hip 
and partly to cold ; supposing it was a return of rheumatism, he took a 
sweat and was cupped upon the hip ; not improving, it was proposed to 
cauterize the rim of the left ear, but an examination of the hip detected an 
aneurismal tumour, which was decided to be of the gluteal artery; the 
patient had perceived pulsations of tumour some weeks ; tumour circum- 
scribed and elastic. On examination the pulsations were found strong and 
synchronous with the heart ; bruit distinct ; tumour cannot be diminished by 
pressure ; was situated about the middle of the os ilii, beginning one and a 
half inches from the top of the trochanter major, projecting five inches, and 
having a vertical measurement of five inches, and a transverse of four and 
a half ; treatment, deligation of the internal iliac artery. 

Operation. — Chloroform administered, but patient became so excited and 
resisted it so powerfully that after six drachms were given it was stopped ; 
incision was five inches long, commencing three-fourths of an inch above 
Poupart's ligament and half an iuch from the epigastric artery, terminating 



I860.] 



Smith, Deligation of the Primitive Iliac Artery. 



23 



one and a half inches above the anterior superior spine of the ilium, about 
four inches from the umbilicus ; the different tissues were raised until the 
internal iliac artery was exposed, which was found pulsating strongly ; this 
vessel was isolated with the finger nail about half an inch from its origin, 
and the aneurismal needle passed under it from within outward, when, upon 
attempting to extricate the ligature from the needle with the left forefinger 
and thumb, there was a sudden hemorrhage of arterial blood, amounting to 
four or five pounds ; the artery collapsed under the fingers ; the index finger 
of the left hand was immediately passed up to the primitive iliac, which 
was also found collapsed ; this vessel was immediately isolated, and a liga- 
ture passed around it with the aid of a silver catheter. 

Progress. — Hemorrhage ceased ; no change in tumour ; limb of normal 
temperature ; symptoms not unfavourable for first two or three days, when 
tympanitis and other symptoms of peritoneal inflammation occurred, and 
he sunk and died on the fourth day. 

Autopsy. — Edges of wound separated ; internal iliac ruptured upon its 
inner surface ; signs of peritonitis ; leg cedematous, calf red, showing signs 
of approaching gangrene. 

Case 8. Rupture of the right external iliac artery; ligature of the 
common iliac; death. By A. M. Edwards, Esq., of Edinburgh. {Monthly 
Journal of Medical Science, January, 1858.) 

History. — Patient was a man, set. 2*1 ; a soldier • three months before 
observation noticed a pulsating tumour in right groin, of the size of an 
apple ; suffered pain in the part, and while bathing it felt something 
suddenly give way in the abdomen, and a sensation of warm fluid flowing 
towards the seat of pain ; pain greatly increased. On examination a 
tumour could be traced in the iliac region, extending from Poupart's liga- 
ment to the umbilicus, without defined limits, and pulsating ; pain in the 
abdomen intense ; on the following day tumour extended to false ribs and 
umbilicus ; skin red ; symptoms aggravated ; diagnosis, iliac aneurism. 

Operation. — Chloroform administered ; incision began two inches inter- 
nal to the anterior superior spine of the ilium and terminated at the last 
rib ; no accident. 

Progress. — Pulsation ceased ; temperature of leg reduced, but recovered 
its warmth ; second day had delirium tremens, but soon recovered ; sixteenth 
day ligature came away; wound healthy; continued to do well until the 
twenty-fifth day, when hemorrhage occurred and quickly proved fatal. 

Autopsy. — Peritoneum adherent and dark coloured ; common iliac artery 
divided at point of ligation, both ends tapering, and plugged ; an aneurism 
size of an orange on external iliac, in which was a recent rent, the seat of 
the hemorrhage. 

Case 9. Aneurism of the ischiadic artery ; ligature of this vessel, and, 
subsequently, of the right common iliac; death. By Wm. J. Holt, M. D., 
late Surgeon in the Crimean War. {Southern Medical and Surgical 
Journal, October, 1859.) 

History. — Patient was a man, set. 24 ; health good ; fell upon hip when 
four years old, five years after first noticed a small tumour in region of 
tuberosity of ischium, which has steadily increased, and latterly has pulsated. 
On examination, a tumour of the size of a goose's egg was found upon the 
inner part of the nates, near the tuberosity of the ischium and extending 
upward in the course of the ischiatic artery, protrudes two inches, is conical, 



24 Smith, Deligation of the Primitive Iliac Artery. [July 

soft, skin blue, pulsation visible, aneurismal thrill marked ; ligature applied 
to the ischiatic artery by Prof. Dugas ; on eighth day severe hemorrhage 
occurred ; on the tenth hemorrhage recurred, and it was decided to apply a 
ligature to the common iliac. 

Operation. — This operation was performed by Dr. Holt; no account 
given ; peritoneum wounded. 

Progress. — On second day temperature of limb normal ; died on the 
third day. No autopsy. 

Case 10. Stab in the inguinal region; profuse hemorrhage ; ligature 
of the right common and internal iliac arteries; death. By Willard 
Parker, M. D., Surgeon to the New York Hospital. (Communicated.) 

History. — Patient, a man, set. 21, carriage-maker, while sporting with a 
companion fell upon a knife having a broad blade, which entered the right 
groin midway between the symphysis pubis and anterior superior spine of 
the os ilii, making a wound an inch in length in the direction of Poupart's 
ligament ; severe hemorrhage occurred, and a knuckle of intestine protruded 
from the wound ; the physician who was called reduced the intestine, and 
applying a bandage firmly, sent him to the hospital ; on removing the dress- 
ings alarming hemorrhage occurred, which was controlled by the finger of 
an assistant, passed into the wound and pressed upon the common iliac ; 
in consultation it was deemed advisable to operate with reference to deliga- 
tion of the common iliac artery. 

Operation. — Incision began a little below the last false rib and termi- 
nated at the wound made by the knife ; no accident ; ligatures were applied 
to the common and internal iliac arteries; a large quantity of blood was 
pressed out of the peritoneal cavity. 

Progress. — Patient, who was in a profound collapse from the loss of 
blood, scarcely rallied under the free use of stimulants, and died ten hours 
after the operation. 

Autopsy. — Internal epigastric artery wounded, and peritoneum opened 
by the stab of the knife ; peritoneal cavity partially filled with coagula ; 
peritoneum not otherwise injured. 

Case 11. Aneurism of the left femoral artery ; ligature of the femoral, 
profunda, external and common iliacs ; death. By Gurdon Buck, M. D., 
Surgeon to the New York Hospital. (New York Journal of Medicine, 
November, 1858.) 

History. — Patient, a man, set. 40 ; mulatto ; dissipated ; first noticed a 
pulsating tumour in the middle third of the left thigh a month before. On 
examination a tumour was found occupying the middle of the thigh, extend- 
ing from four inches below Poupart's ligament to the point where the 
femoral artery pierces the adductor magnus muscle ; raised about an inch, 
and pulsating freely ; bruit loud ; on the night following tumour rapidly 
extended, as if ruptured ; the femoral artery was tied, and as hemorrhage 
occurred from a wound of the artery the incision was extended and ligatures 
successively applied to the external iliac and at two points of the profunda; 
several days after the separation of the ligature from the external iliac 
severe hemorrhage again recurred, and it was decided to apply a ligature 
to the common iliac. 

Operation. — Chloroform administered ; incision continued upward in con- 
tinuation of the former wound about four inches ; peritoneum wounded. 

Progress. — Second day limb of normal temperature ; symptoms favour- 



I860.] Smith, Deligation of the Primitive Iliac Artery. 



25 



able until seventh day, when hemorrhage occurred from the wound ; arrested 
by pressure ; on thirteenth day ligature came away; on the fifteenth and 
sixteenth days hemorrhage recurred ; death on the seventeenth day. 

Autopsy. — Peritoneum not inflamed ; large blood-clot extended upward 
from the right iliac fossa to liver ; blood also extravasated into parts adja- 
cent to wound ; common iliac divided across and ends retracted. 

Group n. Reports of Fifteen Cases of Deligation of the Primitive 
Uiac Artery for the Cure of Aneurism. 

Case 1. Aneurism of the external iliac artery, ligature of the common 
iliac ; recovery. By Y. Mott, M. D., Prof, of Surgery in Rutgers Medical 
College. {American Journal of the Medical Sciences, vol. i. p. 156.) 

History. — Patient, a man, set. 33, a farmer, temperate, healthy, accus- 
tomed to lifting heavy weights ; first noticed a tumour in the lower part of 
the abdomen, two weeks before observation. On examination the abdomen 
on the right side was found enlarged from the crural arch to the umbilicus 
by a pulsating tumour ; had enlarged very rapidly ; caused excessive pain. 

Operation. — Incision began just above the external abdominal ring and 
was carried in a semicircular direction half an inch above Poupart's liga- 
ment, and terminating a little beyond the anterior spinous process of the 
ilium, in extent about five inches; this incision had to be enlarged upwards 
of three inches subsequently; peritoneum was raised upon the finger passed 
into the internal abdominal ring ; circumflex ilii artery was divided ; no 
accident. 

Progress. — Pulsation ceased ; temperature of the limb fell, but was soon 
restored ; no unfavourable symptoms occurred ; ligature separated on the 
eighteenth day; convalescence complete on the forty-fifth day. 

Case 2. Aneurism of the right external iliac artery; ligature of the 
common iliac ; death. By Philip Crampton, M. D., F. R. S., Surgeon 
General to the Forces in Ireland. (Jledico-Chirurg. Trans., vol. xvi.) 

History. — Patient, a man, set. 30, healthy, soldier ; first noticed tumour 
nine months before, after wrestling ; gradually increased, with much pain. 
On examination, tumour was found extending from about three inches below 
the crural arch to within about three inches of the umbilicus, divided by 
Poupart's ligament ; pulsation and thrill distinct at certain points. 

Operation. — Incision began at the anterior extremity of the last false 
rib ; proceeding directly downward to the os ilium, it followed the line of 
the crista ilii, keeping a very little within its inner margin, terminating at 
the anterior superior spine ; no accident ; ligature of moistened catgut 
used. 

Progress. — Pulsation ceased ; tumour immediately diminished one-third; 
temperature of limb reduced slightly; fifty hours after the operation pulsa- 
tion returned in the tumour, but no thrill ; pulsation continued free until 
the eighth day, when the ligature separated ; pulsation became nearly as 
free as before the operation, but wound nearly closed on the tenth day, when 
sudden and profuse hemorrhage occurred from the wound, which proved 
almost instantly fatal. 

Autopsy. — Artery at the point of ligation surrounded by an abscess ; it 
was not cut through, but its internal coats were divided; aneurism far 
advanced towards a cure ; tumour of the size of a walnut ; artery for six 
inches above the sac filled with a firm coagulum. 



26 



Smith, Deligation of the Primitive Iliac Artery. 



[July 



Case 3. Aneurism of the right external iliac artery; ligature of the 
common iliac ; death. By Alexander H. Stevens, M. D., of New York. 
(Communicated.) 

History. — Patient, a man, a farmer, entered the New York Hospital 
with an ill-defined aneurismal tumour in the right inguinal region. 
Operation. — Peritoneum wounded. 
Progress. — Death ten days after operation. 
Autopsy. — Peritonitis. 

Case 4. Aneurism of the left external iliac artery; ligature of the 
common iliac ; recovery. By M. Salomon, of St. Petersburgh. (Zeit- 
schrift fur die gesammte Medicin, Band 12, Heft. 3, 1839.) 

History. — Patient, a man, get. 38, received a kick from a horse in the 
left groin six months before, shortly after which a tumour appeared in the 
inguinal region. On examination, the tumour was found to extend from 
four fingers' breadth below to the same distance above Poupart's ligament, 
and from the anterior superior spine of the ilium to the linea alba ; pulsa- 
tions strong ; skin thin and distended. 

Operation. — Incision began an inch on the inner side of the anterior 
spinous process, and ran parallel with the inferior epigastric artery to 
within an inch of the last false rib, being four and a half inches long ; no 
accident. 

Progress. — Pulsation ceased and tumour rapidly diminished ; limb be- 
came cool at first, but regained its natural warmth ; on the third day a 
gangrenous eschar formed on the foot, and subsequently others appeared ; 
general condition favourable ; ligature separated on the thirty-second day; 
convalescence complete at the end of two months. 

Case 5. Aneurism of the right external iliac artery; obscurity delay- 
ing an operation; mortification of the limb; ligature of the common iliac 
and amputation of the thigh; death. By James Syme, Esq., Prof. Clinical 
Surgery. (Edinburgh Medical and Surgical Journal, October, 1838.) 

History. — Patient, a man, set. 31, a tailor, unhealthy, first noticed a 
pulsating tumour in the right groin three months before, rapidly increased. 
On examination a large tumour was found occupying the whole space be- 
tween the pubes and the crest of the ilium, tense and elastic, having a very 
obscure pulsation in some parts, aneurismal bruit distinct ; tumour rapidly 
enlarged ; limb became oedematous ; pain in knee intolerable ; the leg at 
length became cold, and incipient mortification apparent ; pulsation of tu- 
mour distinct and the aneurismal character well-marked, when it was decided 
to ligate the common iliac. 

Operation. — Incision began a little above the external abdominal ring 
and extended in a curved direction upward six or seven inches ; no accident. 

Progress. — Tumour became smaller and softer ; mortification extended : 
on third day limb was amputated ; death on the fourth day. 

Autopsy. — Signs of peritonitis ; nodular inequalities of the surface of 
tumour due to enlarged glands ; external iliac and femoral involved in the 
aneurism. 

Case 6. Aneurism of the right external iliac artery; ligature of the 
common iliac; recovery. By Edward Peace, M. D., Surgeon to the 
Pennsylvania Hospital. (American Journal of the Medical Sciences, 
April, 1843.) 

History. — Patient, a man, set. 36, healthy; first noticed the tumour five 



I860.] Smith, Deligation of the Primitive Iliac Artery. 21 

months before, a few days after having "felt something give way in the 
right groin," while lifting for a wager ; suffered from pain in the part and 
along the course of the crural nerve, but continued to labour until a fort- 
night before observation. The tumour was of pyriform shape, extending 
from three inches below to three inches above Poupart's ligament, and 
divided into two lobes by that ligament ; pulsation free ; thrill faint ; very 
sensitive on pressure ; skin over tumour red ; countenance of patient 
anxious. 

Operation. — Incision seven inches in length, commencing on a level with 
the umbilicus and two inches from median line, terminating half an inch 
above the external ring ; no accident. 

Progress. — Pulsation of tumour ceased ; entire limb below the middle of 
the thigh at once became cold and insensible ; but gradually the natural 
temperature and sensibility returned to the leg and foot on the second and 
third days. On the fifth day the tumour became hot and swollen, but these 
symptoms soon disappeared; ligature separated on the thirty-second day; 
five months after the operation the tumour had diminished to the size of a 
filbert ; no return of pulsation was ever noticed. 

Case 7. Aneurism of the left external iliac artery; ligature of the 
common iliac; recovery. Richard Hey, Surgeon to the York County 
Hospital. (Medico- Chirurgical Transactions, vol. xxvii.) 

History. — Patient, a man, set. 41 ; first noticed a tumour in the left 
groin twelve days before observation ; on the night following its recogni- 
tion was suddenly seized with severe pain, and the tumour rapidly enlarged. 
On examination the tumour was found to have the characteristic signs of 
aneurism ; continued to enlarge rapidly, and finally occupied the whole of 
the left iliac fossa, having a vertical diameter of six inches and a transverse 
diameter of six and a half inches, and projecting at least three inches. 

Operation. — Incision began two and three-quarters inches above the 
umbilicus, three inches to the left of the median line, and was six inches in 
length, the lower extremity being moderately curved ; no accident. 

Progress. — Temperature of the limb but slightly affected ; no unfavour- 
able symptom occurred; ligature separated on the twenty -eighth day; 
complete convalescence about the sixth week. 

Case 8. Aneurism of the external iliac artery; ligature of the com- 
mon iliac ; death. By Dr. Guatano G-arviso, of Monte Yideo, South 
America. (Annal. de la Chirurgie, November, 1844.) 

History. — Aneurism of the external iliac, extending so high as to pre- 
vent the application of a ligature to that artery. 

Operation. — Incision made with a view to secure the external iliac. 

Progress. — Ligature separated on the thirty-sixth day ; recovered. 

Case 9. Aneurism of the left external iliac artery ; ligature of the 
common iliac; death. By Wm. Lyon, Esq., Lecturer on Surgery, &c. 
(Monthly Journal of Medical Sciences, vol. viii.) 

History. — Patient, a man, aet. 53, healthy; first noticed oedema of his 
left leg, and soon after had some pain in the hip and thigh, which led to 
the detection of a small aneurismal tumour in the inguinal region. 

Operation. — Incision seven inches in length, commencing two inches 
within the anterior superior spinous process ; no accident. 

Progress. — Pulsation at first ceased, but soon returned feebly; tempera- 
ture of limb reduced, with numbness ; died fifty-four hours after operation. 



28 Smith, Deligation of the Primitive Iliac Artery. [July 

Autopsy. — No trace of peritonitis ; tumour not more than one-third the 
size it was before the operation ; lay beneath Poupart's ligament ; parts in 
the track of the wound healthy. 

Case 10. Aneurism of the right external iliac artery; ligature of the 
common iliac ; death. By Ellis Jones, Esq., Surgeon to the Northern 
Hospital, Liverpool. (London Journal of Medicine, vol. iv.) 

History. — Patient, a man, set. 34, coal-heaver ; felt something give way 
in the groin four months before observation, but did not notice a tumour 
for three months after ; no pain. On examination a tumour was found, 
size of a cricket-ball, of a round shape, above Poupart's ligament, pulsating 
freely; fourteen days after the tumour had increased, filled the iliac fossa, 
very painful, skin inflamed. 

Operation. — Chloroform administered ; incision began two and three- 
quarter inches above the navel, and a little more than three inches on the 
right of the median line, and was carried down five inches ; no accident. 

Progress. — Pulsation ceased ; temperature of limb unchanged ; second 
day erysipelas appeared at the wound, and gradually extended over the hip, 
causing sloughs and purulent collections ; fourteenth day intestines appeared 
in wound ; death on fifteenth day. 

Autopsy. — No appearance of peritonitis ; aneurismal sac empty, and its 
coats in a gangrenous state ; surrounding tissues, iliac, and gluteal muscles 
converted into a soft, pulpous mass ; common iliac healthy. 

Case 11. Aneurism of left femoral and external iliac artery ; ligature 
of the common iliac ; death . By A. J. Wedderburn, M. D., Surgeon to 
the Charity Hospital, New Orleans. (New Orleans Medical and Surgical 
Journal, May, 1852.) 

History. — Patient, a man, ast. 25 ; first noticed the tumour three months 
before ; rapidly increased. On examination a large aneurismal tumour was 
found extending above and below Poupart's ligament; thigh flexed on 
body; pain severe. 

Operation. — Incision began four or five inches above Poupart's ligament 
and extended in a slight curve to near the anterior superior spine ; severe 
hemorrhage occurred ; no accident. 

Progress. — Pulsation ceased ; on second day limb was cold and insen- 
sible below the knee, with livid spots ; gangrenous ; on fourth day gangrene 
extended to hip ; death on fourth day. 

Autopsy. — No appearances worthy of notice. 

Case 12. Aneurism of the right external iliac artery; ligature of the 
common iliac; suppuration of the sac ; death on the fourth day. By W. 
H. Yan Buren, M. D., Prof, of Anatomy in the Univ. Med. College, N. Y. 
(New York Journal of Medicine, January, 1857.) 

History. — Patient, a male, sat. 46,. of irregular habits, addicted to the 
inordinate use of tobacco, stimulants, and opium ; very obese ; tumour first 
recognized by patient four years before, large as a hickory nut, and was of 
spontaneous origin ; at time of coming under observation it was the size* 
of a child's head at birth, somewhat flattened upon its surface, occupying 
the fold of the groin, and extending upwards beneath Poupart's ligament, 
in the course of the external iliac artery. An operation was declined by 
the patient for six months, during which time the tumour increased greatly 
in size, became the seat of severe pain, and finally began to threaten rup- 
ture. 



I860.] Smith, Deligation of the Primitive Iliac Artery. 



29 



Operation. — Chloroform administered ; incision eight inches in length, 
commencing about midway between the most prominent point of the iliac 
crest and the umbilicus, and terminating below over the external abdominal 
ring; no accident. 

Progress. — Pulsation ceased ; temperature of limb fell, but soon reco- 
vered its normal warmth ; symptoms favourable until the close of the second 
day, then a chill occurred, when the tumour, which had diminished to about 
one-third its original size, became tender and painful ; restlessness followed, 
his strength failed, and death took place at the close of the fourth day. 

Autopsy. — The tumour and the parts around it were found to have been 
the seat of inflammation and suppuration ; no signs of peritonitis ; artery 
above and below the ligature filled with a firm coagulum. 

Case 13. Aneurism of the right external iliac and femoral arteries; 
ligature of the external iliac; return of pulsation in the aneurism with- 
out enlargement or inconvenience from the tumour for two years; sudden 
increase in the aneurism ; ligature of the primitive iliac ; death. By 
Stephen Smith, M. D., Surgeon to Bellevue Hospital, N. Y. {New York 
Journal of Medicine, March, 1860.) 

History. — Patient was a female, ast. 33, healthy; two years ago, while 
lifting a tub of water, having one knee pressing against the tub, she felt 
something snap in her right groin, but had no inconvenience until evening, 
when that limb became stiff and lame. On the following day this stiffness 
was much increased, and three or four days later she experienced sharp, 
stinging pains over the anterior surface of that thigh ; several days after 
this she first noticed a small tumour, the size of an almond, just below 
Poupart's ligament ; about three weeks after (October 4, 1856) she entered 
Bellevue Hospital, and came under the care of Dr. Lidell. The tumour 
was the size of a hen's egg, and being recognized as an aneurism, the ex- 
ternal iliac artery was tied. She recovered from this operation, the tumour 
diminishing somewhat in size at first, but pulsation soon after returned. 
She refused further treatment, and left the hospital. She was readmitted 
August 21, 1858, the tumour having again begun to increase, and causing 
great pain down the leg. On examination the tumour was found to be 
somewhat flattened, more than half of its volume being below Poupart's 
ligament, and having a diameter of about three inches ; pulsation and bruit 
very distinct ; pain down the front and inner aspect of thigh intense. After 
remaining in the hospital about a month, during which the tumour gradu- 
ally enlarged, and her sufferings increased in severity, it was determined to 
apply a ligature to the primitive iliac. 

Operation. — Chloroform administered ; incision commenced near the 
extremity of the last rib and terminated at the internal abdominal ring, 
the upper two-thirds of the incision being straight and the lower third 
curved inwards, the curve being quite sharp near the termination of the 
wound. Some difficulty was experienced in the dissection, owing to the 
agglutination of the tissues following the former operation ; no accident ; 
not more than an ounce of blood lost ; primitive iliac enlarged to nearly 
the size of the normal abdominal aorta. 

Progress. — Pulsation ceased ; temperature of limb normal ; pain gradu- 
ally diminished ; opium was freely administered in anticipation of perito- 
nitis ; the external wound united by first intention, except where occupied 
by the ligature ; suppuration became free at this point ; symptoms con- 
tinued favourable until the thirtieth day, when slight hemorrhage occurred 



30 



Smith, Deligation of the Primitive Hiac Artery. 



[July 



at the wound, the ligature being still firm • hemorrhage recurred for several 
days ; ligature separated on the thirty-sixth day, with free discharge of 
pus ; no hemorrhage for a week, during which time the patient's general 
condition rapidly improved. On the fortieth day blood again appeared in 
the wound, and from th^t time to her death, on the forty-eighth day after 
the operation, the hemorrhage became more and more frequent, and though 
frequently almost instantly controlled by pressure upon the abdominal aorta, 
the total amount of blood lost was very great. 

Autopsy. — External wound united firmly, except at the lower point ; a 
large abscess occupied the iliac fossa, filled with grumous blood and com- 
municating with the artery at the point where the ligature was applied ; 
artery completely severed by ligature, the upper extremity being partially 
filled with a coagulum, but allowing the escape of the injection thrown into 
the aorta : aneurism in an advanced state of consolidation. 

Case 14. Aneurism of left external iliac and femoral arteries ; liga- 
ture of common iliac with silver ivire; death. By Warren Stone, Iff. D., 
Prof, of Surgery in University of Louisiana. (Mew Orleans Medical and 
Surgical Journal, September, 1859.) 

History. — Patient, a man, set. 36 ; first noticed the tumour eight months 
before observation. On examination it was found extending from two 
inches below to two and a half inches above Poupart's ligament ; pulsation 
strong. 

Operation^ — Incision was made from upper edge of tumour in the course 
of thejinea semilunaris upward to the cartilage of the ribs; peritoneum 
lacerated ; silver wire passed under the artery by means of a silk ligature, 
and ends cut close. 

Progress. — Limb became cooler, but soon recovered its natural warmth ; 
tumour diminished favourably, but a severe dysentery supervened, from 
which the patient sank, and died on the twenty-sixth day after the opera- 
tion. ~No autopsy made. 

Case 15. False aneurism from ulceration of the femoral artery in 
the groin, consequent upon the pressure of the dislocated head of the os 
femoris ; ligature of the primitive iliac artery; death. By Middleton 
Goldsmith, M. D., Prof, of Surgery in the Kentucky School of Medicine. 
(Louisville Medical Journal, February, 1860.) 

History. — Patient, a man, aet. 40, labourer; had his left femur dislocated; 
the head of the bone being thrust under Poupart's ligament overrode the 
margin of the pelvis in such a manner as to underlie the femoral artery ; it 
remained unreduced for two months, when he came under observation with 
a diffused swelling occupying the groin, filling the iliac fossa, and extending 
to the middle of the thigh ; feeble pulsation ; tumour appeared a few days 
after accident; pain severe; diagnosis, aneurism; treatment, ligature of 
common iliac. 

Operation, — Patient etherized ; incision began at edge of rectus on left 
side, traversed the course of the common iliac obliquely, and terminated 
near the crest of ilium ; peritoneum freely opened. 

Progress. — Natural warmth returned to limb within twenty-four hours ; 
progressed favourably until the fourth day; opium freely administered; 
delirium supervened on third day, which continued until the fifth day, when 
vomiting occurred, and death. 

Autopsy. — Wound nearly healed; peritoneum adherent where incised, 
but no trace of peritonitis ; ligature in place ; firm coagula extending above 



I860.] Smith, Deligation of the Primitive Iliac Artery. 31 

to aorta, and below into external and internal iliac ; femoral and external 
iliac arteries perforated to the extent of an inch on the postero-external 
aspect ; head of femur in cavity of aneurism. 

Group III. Beports of Four Gases of Deligation of the Primitive Iliac 
Artery for the Cure of Pulsating Tumours simulating Aneurisms. 

Case 1. Malignant tumour simulating aneurism ; ligature of the right 
common iliac artery ; recovery. By G. J. Guthrie, Esq., Surgeon to 
Westminster Hospital. {London Medical Gazette, vol. ii., 1834.) 

History. — Patient, a female, set. — , had long suffered from pain in the 
hip ; received an injury to the hip, and soon after noticed a pulsating 
tumour, size of a hen's egg ; rapidly increased for a year. On examination, 
the tumour was found of the size of an adult person's head, situated upon 
the right buttock, and so inconvenient as to prevent her lying upon that 
side ; diagnosis, aneurism. 

Operation. — Incision began about an inch below and inside of the ante- 
rior superior spine of ilium, and was carried upward and diagonally inward, 
terminating above the umbilicus, in length between six and seven inches ; 
peritoneum opened at both extremities of wound. 

Progress. — Pulsation ceased ; temperature of limb fell slightly, but by 
friction was soon restored ; no bad symptoms ; tumour diminished one half 
in a month ; ligature separated on the twenty-sixth day • at the end of two 
months was entirely recovered from operation. 

The tumour began again to enlarge at the end of three or four months, 
and she died about eight months after the operation. The post-mortem 
examination revealed the existence of an immense encephaloid tumour, 
occupying the right iliac region. 

Case 2. Malignant tumour simidating an aneurism ; ligature of the 
left common iliac artery; death. By Edward Stanley, Esq., Surgeon 
to St. Bartholomew's Hospital. (Medico- Chirurgical Transactions, vol. 
xxviii.) 

History. — Patient was a man, set. 42, a butler by profession, temperate, 
complexion sallow; had pain in left hip for last four years, which was 
considered rheumatic. On examination, the tumour was found connected 
with the ilium in about the anterior half of its extent, projecting from both 
surfaces, but principally from the abdominal, extending upward to the crista, 
downward to Poupart's ligament, and along its outer half into the cavity 
of the abdomen ; portion of crista which bounded tumour above was thick- 
ened, and a small piece of movable bone was discovered, involved in the 
tumour, near the anterior superior spine ; pulsation everywhere marked, 
and a bellows sound plainly recognized ; diagnosis, aneurism. 

Operation. — ISTo account of the operation is given. 

Progress. — Forcible pulsation noticed in the circumflex ilii artery imme- 
diately after the operation ; limb rendered numb and cold, but recovered its 
temperature and sensation ; second day vomiting ; sank and died on the 
morning of the third day. 

Autopsy. — Peritoneum showed marked effects of inflammation ; track of 
wound suppurating ; tumour malignant, growing from the periosteum ; 
through the anterior two-thirds of the tumour the ilium was only perfor- 
ated with foramina, but in the remaining third the integrity of the bone 
was destroyed, being separated into loose fragments, and a communication 
through to the opposite surface being thus opened. 



32 



Smith, Deligation of the Primitive Iliac Artery. [July 



Case 3. Malignant tumour simulating aneurism of the left external 
iliac artery; ligation of the common iliac ; death. By C. H. Moore, Esq., 
Surgeon to the Middlesex Hospital. {Lancet, Feb. 21, 1852.) 

History. — Patient was a man, set. 52 ; had pain and swelling of the left 
leg ; leg had been cedematous for ten weeks previously, and large veins per- 
meated the skin ; it was soon discovered that this oedema and pain were due 
to the existence of a large pulsating tumour in the left iliac region ; its 
boundaries were easily denned through the abdominal walls; pulsation 
strong and distinct, and synchronous with the heart ; diagnosis, aneurism 
of the external iliac; increased rapidly in size, and pulsations more marked. 

Operation. — No account given. 

Progress. — Pulsation ceased ; symptoms favourable for a short time ; 
died a few days after the operation. 

Autopsy. — A large encephaloid tumour was found lying in contact with 
the iliac arteries. 

Case 4. Osteo-aneurism of the pelvis ; ligation of the right common 
iliac; death. By C. Th. Meir, M. I)., Surgeon to Bellevue Hospital. 
(American Medical Gazette, May, 1859.) 

History. — Patient, a man, set. 59, workingman in a jewelry-shop, has 
felt great pain from the right groin to knee for last two years ; six months 
ago fell upon right hip, and was so disabled as to be compelled to use 
crutches ; a week before observation made a misstep, which rendered his 
foot useless. On examination there was found shortening of the leg, the 
trochanter being nearer the anterior superior process, with crepitus over the 
trochanter ; right iliac fossa filled with a large, somewhat yielding, pulsating 
tumour, over which the external iliac .artery could be traced ; hip, from crest 
of ilium to fold of nates, and from Poupart's ligament across to sacrum, 
much enlarged; swelling had no definite boundary; remainder of ilium 
traceable, but of twice its normal size ; strong pressure in the iliac fossa 
caused a perceptible protrusion upon the external surface of ilium ; tem- 
perature of limb lower than the other ; pulsations strong over the entire os 
ilium, at the ischiatic notch, giving to the fingers the feeling of friction ; 
pressure over the iliac artery caused a diminution, but not cessation, of the 
bellows sound ; diagnosis, doubtful. 

Operation. — Chloroform administered ; incision began two fingers' breadth 
above and within the anterior superior spinous process, and terminated half 
an inch above the middle of Poupart's ligament ; no accident. 

Progress. — Pulsation ceased ; temperature of leg lower than the left ; 
second day loss of sensation in lower part of thigh ; discoloration of wound 
and thigh ; third, discoloration increasing ; fourth, wound dark, neigh- 
bouring parts inflamed ; toes and sole of foot black ; gangrene of leg con- 
tinued to extend until, it reached the hip, when death took place, twelfth 
day after the operation. 

Autopsy. — Recent peritonitis and slight adhesion of intestines; large 
arteries of pelvis in normal condition ; right half of pelvis involved in the 
disease, which consisted of the residue of the original bony material and of 
cavernous tissue of new formation, in which were imbedded loose bones ; 
acetabulum destroyed ; head of femur a mere shell, and neck destroyed. 



I860.] 



Smith, Deligation of the Primitive Iliac Artery. 



33 



Group IY. Unclassified Cases. 

Case 1. Aneurism by anastomosis of the labise pudendde of an infant ; 
ligature of the right common iliac artery; death from erysipelas on the 
thirty -seventh day. By George Bushe, M. D. (New York Medico- 
Chirurgical Bulletin, vol. i.) 

History. — Patient was a female, set. six weeks and four days ; tumour 
of a vermilion colour, mammillated, compressible, pulsating, elevated half 
an inch, involving all the left side of the perineum, verge of the anus, rec- 
tum, labium, vagina, urethra ; disease has existed from birth, but did not 
at first extend over the perineum ; has two ulcerated points, from which 
severe and dangerous hemorrhage has occurred five times ; one attack at- 
tended with slight convulsions ; last hemorrhage controlled by pressure ; is 
pale, nurses well. 

Operation. — Incision began at the junction of the middle and external third 
of a line drawn from the anterior superior spine of the ilium and umbilicus 
and extended in a curved direction to the internal abdominal ring ; this 
incision was afterward enlarged half an inch upward; several arteries 
required the ligature ; no accident. 

Progress. — Pulsation of tumour ceased ; limb slightly colder, and on the 
second day 6° lower temperature than the other ; continued to do well until 
the tenth day, when erysipelas of the thigh made its appearance ; eleventh 
day, wound slightly erysipelatous ; thirteenth day, ligature separated, and 
the tumour had nearly disappeared ; twenty-second day, wound closed, matter 
forming at the knee, health failing ; sunk and died on the thirty -seventh day 
from the suppuration about the knee and a renewed attack of erysipelas. 

Autopsy. — Right common iliac artery obliterated from point of ligation, 
to bifurcation of aorta. 

Case 2. Encephaloid tumour of the internal and superior aspect of the. 
thigh, extending to the foramen ovale ; ligature of the primitive iliac ; 
removal of the tumour ; death. By E. Chassaignac, Surgeon to PHopital 
St. Antoine, Paris. (Bulletin de la Societe de Chirurgie de Paris. Paris, 
1851.) 

History. — Patient was a man, set. 49, a cooper, of good general health ; 
first noticed a swelling on the inner and upper part of the left thigh ; pain 
is felt to the lower third of the thigh ; the tumour soon enlarged to the size 
of a large walnut, and then remained four months without any increase of 
volume ; the patient continued at his occupation during this period without 
inconvenience ; the two following months the tumour, without appreciable 
cause, increased steadily in size, attended with lancinating pains and a feel- 
ing of tension extending to the foot ; during the last three weeks the tumour 
increased very rapidly, its volume becoming enormous, and so interfering 
with the patient that he was obliged to abandon his work and enter the 
hospital. On examination a tumour was found at the junction of the left 
thigh and the pelvis, towards its superior and internal part, extending 
obliquely from the middle of the crural arch downward twelve centimetres, 
and terminating posteriorly at the postero-internal part of the thigh, on, a 
level with the tuberosity of the ischium ; it seemed to be developed in the 
course of the descending branch of the os pubis and of the ascending branch 
of the os ischii ; it did not appear to extend into the pelvis by any pro- 
longation ; it was but slightly movable, apparently adherent to bone, was 
covered by healthy skin, and was under the adductor muscles ; to the touch 
it was solid, without fluctuation ; no bruit perceptible or pulsation ; the 
No. LXXIX.— July 1860. 3 



34 



Smith, Deligation of the Primitive Iliac Artery. 



[July 



femoral artery runs along its external border, its pulsations being well- 
marked above ; examination per rectum reveals nothing ; the leg preserves 
its normal heat and sensibility; no oedema; exploration with a fine trocar 
at two different points obtained only blood ; diagnosis, an encephaloid 
tumour attached to the os ischii and the descending ramus of the os pubis, 
without prolongations into the pelvis, but surrounding the foramen ovale ; 
treatment, extirpation of the morbid growth. 

In order to prevent the hemorrhage which must necessarily attend the 
removal of a tumour so large and in that situation, M. Chassaignac pro- 
posed to ligate the primitive iliac artery, and thus cut off the supply of 
blood through the hypogastric artery; a ligature applied to the femoral 
would only cause a reflux of blood through the surrounding arteries, and 
hence increase rather than diminish the dangers of severe hemorrhage. 

Operation. — Chloroform administered ; incision began an inch above the 
inguinal ring and extended upward four inches, terminating about a finger's 
breadth from the false ribs ; no accident. The tumour was then removed 
with scarcely the appearance of blood ; operation lasted half an hour. 

Progress. — The patient being long under the influence of chloroform 
was pale, pulse small but regular, complained of sharp pains in the knee and 
thigh of the affected side ; five hours after operation the heat of the limb was 
partially restored, but did not equal that of the opposite side ; thirst exces- 
sive ; painful cramps ; in the night patient became feeble, delirium super- 
vened, and he died at four o'clock on the following morning. 

Autopsy. — Peritoneum not injured ; no trace of hemorrhage ; ligature 
applied at the point where the primitive iliac divided into the external and 
internal branches ; a fibrinous clot filled the artery above the ligature, and 
similar clots filled both the external and internal iliacs. 

In order to present these cases in a proper relation for study and refer- 
ence the following tables are introduced : — 

Group I. — Summary of Eleven Cases of Deligation of the Primitive Iliac 
Artery for the Arrest of Hemorrhage. 



Operator. 



Disease or accident. 



Kesult. 



Date of Cause of 
death. death. 



1 Gibson 

2 Liston 

3 Garviso 
4jPirogoff 
5|Deguise 

6 Post 

7 Uhde 
Edwards 
Holt 
Parker 
Buck 



38 



20 R. 
40L. 



Gunshot wound of external Died 

iliac artery 
Hemorrhage after amputation Died 

of thigh 

Hemorrhage from bursting of Died 

aneurism 
Hemorrhage after ligature of jDied 

external iliac 
Hemorrhage after ligature of Cured 

the external iliac 
Hemorrhage from an incision; Died 

into an aneurism 
Rupture of internal iliac inDied 

applying ligature 
Rupture of an aneurism of Died 

external iliac. 
Hemorrhage from opening a'Died 

gluteal aneurism 
Hemorrhage from a stab in'Died 

the groin 
Hemorrhage after ligature of Died 

external iliac 



15th day j Hemorrhage 
24 hours !Exhaustion 

4 hours Exhaustion 

j 

14th day Hemorrhage 

24 hours Exhaustion 
4th dayjperitonitis 
25th day Hemorrhage 



3d day 
10 hours 



Exhaustion 
Exhaustion 



17th day Hemorrhage 



I860.] Smith, Deligation of the Primitive Iliac Artery. 



35 



Remarks on the first Group. — Upon reviewing this group of cases the 
following points of interest are presented : — 

1. Disease or Accident. — Of eleven cases of deligation of the primitive 
iliac artery for the arrest of hemorrhage, in two cases the operation was 
performed for wounds in the inguinal region, of which one involved the 
external iliac and the second the internal epigastric, both proved fatal, one 
from secondary hemorrhage, the other from exhaustion consequent upon 
the primary hemorrhage ; in one for secondary hemorrhage from stump 
after amputation of thigh, death from immediate exhaustion ; in two from 
rupture of an aneurism, one internally and the second externally, both fatal, 
the former from secondary hemorrhage and the latter from immediate 
exhaustion ; in three from hemorrhage after ligation of the external iliac, 
one cured, the other two fatal from secondary hemorrhage ; in two from 
incisions into aneurismal tumours, both fatal from immediate exhaustion ; 
in one from rupture of internal iliac, in attempting its ligation for aneurism 
of the gluteal artery. 

2. Result. — Of eleven cases, ten were fatal, one recovered, being a mor- 
tality of nearly 91 per cent. The success of this operation upon the primi- 
tive iliac artery, for the causes above assigned, presents a striking contrast 
with the operation upon the external iliac for the same class of diseases 
and accidents. Of fourteen cases of deligation of the external iliac artery 
for the arrest of hemorrhage, I find that eleven were successful and three 
fatal, the mortality being about 21 J per cent. 

3. Date of Death. — The earliest period of death after the operation was 
four hours ; latest, twenty-fifth day ; average, eight days. 

4. Cause of Death. — Secondary hemorrhage, four ; immediate exhaus- 
tion, five ; peritonitis, one. 

A proper appreciation of the circumstances under which the primitive 
iliac artery has been tied for the arrest of hemorrhage will lead the dis- 
criminating surgeon, notwithstanding the excessive mortality that has thus 
far attended its performance, to accord to this operation an important place 
among the resources of his art. In the immediately fatal cases the patient 
was already excessively prostrated by the hemorrhage, and the operation 
has been performed when a fatal termination appeared inevitable : but even 
in these cases it has relieved the most threatening symptoms, and given 
promises of successful results. In the remaining cases the fatal issue has 
been due to causes unconnected with the operation itself, but referable to 
some intercurrent affection. 



36 Smith, Deligation of the Primitive Iliac Artery. [July 



Geoup II. — Summary of Fifteen Cases of Deligation of the Common Iliac 
Artery for Aneurism. 



6 


Operator. 


a> 

CO 


<B 
<! 


Seat of aneurism. 


Kesult. 


Date of 
death. 


Cause of death. 


1 


Mott 


M. 


33 


Right external iliac 


Cured 






2 


Crampton 


M. 


30 


Right external iliac 


Died 


10th day 


Hemorrhage 


3 \ Stevens 


M. 




Right external iliac 


Died 


2d day 


4 1 Salomon 


M. 


38 


Left external iliac 


Cured 




5 Syme 


M. 


31 


Right external iliac 


Died 


4th day 


Gangrene of leg 


6 


Peace 


M. 


36 


Right external iliac 


Cured 


7 Hey 


M. 


41 


Left external iliac 


Cured 






8 


Garviso 






External iliac 


Cured 






9 Lyon 


M. 


53 


Left external iliac 


Died 


50 hours 


Exhaustion 


10 


Jones 


M. 


34 


Right external iliac 


Died 


15th day 


Erysipelas 


11 


Wedderburn 


M. 


25 


Left fern., ext. iliac 


Died 


4th day 


Gangrene 


12 


Van Buren 


M. 


46 


Right external iliac 


Died 


4th day 


Suppuration of sac 


13 


Stephen Smith 


F. 


33 


Right external iliac 


Died 


48th day 


Hemorrhage 


14 


Stone 


M. 


36 


Left external iliac 


Died 


26th day 


Dysentery 


15 Goldsmith 


M. 


40 


Left external iliac 


Died 


5 th day 


Exhaustion 



Remarks on the second Group. — On examining this group it appears 
that fourteen of the subjects of the operation for aneurism were males, and 
but one a female ; that the right external iliac artery was affected in eight 
cases, the left in six cases ; one not given ; that the mortality was 66f per 
cent. 

Of the cases which are reported as having recovered we have the follow- 
ing subsequent notices : M. Salomon's patient died ten months after the 
operation, exhausted by the discharge from an abscess which formed upon 
the affected side, and was opened below Poupart's ligament. Dr. Peace's 
patient came under observation a second time, about fourteen months after 
the operation, having remained perfectly well up to within two weeks of 
the latter date, and able to pursue his business of loading boats with stones. 
He then first noticed a return of the tumour, which, on examination, was 
of the size of a small orange, soft, free from pulsation, presenting evident 
marks of fluctuation, the skin covering it being discoloured. A few days 
afterward an opening took place in it, and was followed by considerable 
hemorrhage, which was arrested by compression. Several recurrences of 
hemorrhage took place, and eleven days after this second observation he 
died. 

Of the fatal cases the following explanation should be made : Crampton 
evidently attributed the failure of his operation to the employment of an 
animal ligature, which was of catgut, and " had been dissolved by the heat 
and moisture of the wound and thrown off before the obstruction of the 
artery or the coagulation of the blood in the aneurismal sac had been com- 
pleted. It further appeared that the dissolution of the ligature had caused 
a small abscess to form in the place which it occupied." In Mr. Syme's 
case gangrene of the limb had already become apparent before the operation 



I860.] Smith, Deligation of the Primitive Iliac Artery. 3? 



was performed. Dr. Stone's patient was in a fair way to recover when 
attacked with dysentery, from which he sunk exhausted. 

A just appreciation of the results in these fifteen cases would give the 
following conclusions : recoveries, five ; permanently cured, one (Mott) ; 
temporarily, two (Salomon, Peace) ; unknown, two (Hey, Garviso) ; died, 
ten; fault of ligature, one (Crampton) ; condition of patient most unfa- 
vourable at time of operation, two (Syme, Yan Buren) ; intercurrent dis- 
ease unconnected with operation, one (Stone) ; connected with operation, 
three (Stevens, Jones, Wedclerburn) ; local disease due to operation, one 
(Stephen Smith) ; cause of sinking and death uncertain, one (Goldsmith) ; 
attributed to operation, one (Lyon). 

The results of the operation of deligation of the common iliac artery for 
aneurism, as compared with the same operation upon the external iliac, is 
worthy of notice. In ninety-five cases, which I have examined, of ligation 
of the latter artery for aneurism, sixty-nine recovered and twenty-six died, 
being a mortality of about 27 per cent., or less than half the mortality of 
the same operation for the same disease when performed upon the common 
trunk. The cause of death in eleven cases, or nearly one-half, of ligation 
of the external iliac for aneurism was mortification of the limb, presenting 
a striking contrast with the same operation upon the primitive iliac, in 
which there was but one instance in eight cases. 



Group III. — Summary of Four Cases of Deligation of the Common Iliac 
Artery for Malignant Tumours simulating Aneurisms. 



No. 


Operator. 


Sex. 


Age. 


Seat of disease. 


Eesult. 


Date of death. 


Cause of death. 


1 


Guthrie 


F. 




Right hip 


Cured 






2 


Stanley 


M. 


42 


Left os ilii 


Died 


3d day 


Peritonitis 


3 


Moore 


M. 


52 


Left iliac region 


Died 


Few days 




4 


Meier 


M. 


59 


Right os ilii 


Died 


12th day 


Gangrene of limb 



Remarks on the third Group. — In this group of cases the operation was 
undertaken in ignorance of the true nature of the disease, although this was 
suspected in at least three cases, and a differential diagnosis was attempted. 
In Mr. Guthrie's case there was at first a difference of opinion among the 
surgeons who examined the tumour. Mr. Guthrie was doubtful on his first 
examination, but finally decided that it was an aneurism; Sir Astley Cooper 
and Mr. Thomas had no doubt of its being an aneurism, and Mr. Keate at 
first regarded it as a malignant tumour, but subsequently concurred in the 
opinion of his associates. In Mr. Stanley's case there was a preponder- 
ance of opinion in favour of the aneurismal character of the tumour. I 
can only learn of Mr. Moore's case that the disease was considered an 
aneurism of the external iliac. In Meier's case the question was decided, 
after a careful review of the various evidences, in favour of an aneurism. 

The determination of the exact nature of pulsating tumours, which often 



38 Smith, Deligaiion of the Primitive Iliac Artery. [July 

strikingly simulate aneurisms in the prominent signs, as developed by a 
physical exploration, and yet may differ essentially, is of great import- 
ance to the surgeon. Without entering into the question of diagnosis, it 
may not be irrelevant to call attention to the marked resemblance of some 
of the main features of cases two and four in this group, and the absolute 
differences between these cases and those of any form of aneurism which the 
entire collection presents. 



Group IT. — Tivo Cases not classified. 



6 


Operator. 


X 

<u 
32 


s 


Disease. 


Artery 
ligated. 


Kesult. 


Date of 
death. 


Cause of 
death. 


1 

2 


Bushe 
Chassaignac 


P. 

M 


6 w. 

49 y. 


Aneurism by anas- 
tomosis 

To prevent hemor- 
rhage 


Left com. 

iliac 
Right com. 

iliac 


Died 
Died 


37th 
day 
4 h'rs 


Abscess of 
knee 
Exhaustion 



Bemarks on the fourth Group. — The cases in this group are of great 
interest, chiefly on account of the diseases or indications which led to the 
operation. In Bushe's case the disease was of a most formidable character, 
and the reasons which led this skilful surgeon to undertake its cure by so 
grave an operation were well conceived, as the result proved. Although 
this case is classified among those reported as unsuccessful, yet it does not 
properly belong to that list, for the patient had nearly recovered, not only 
from the operation, but also from the original disease itself, when she was 
attacked with erysipelas, to the remote effects of which she eventually suc- 
cumbed. This case is also deserving of special mention, from the age of 
the infant patient, which was but six weeks old, being the youngest in the 
collection. 

The second case in this group is one of the most remarkable in the whole 
series, when considered with reference to the object of the operation. We 
cannot present a better comment upon the several points of interest which 
are suggested by its perusal, than will be found in the following abstract of 
the remarks elicited from the members of the Societe de Chirurgie, upon the 
narration of the case by the distinguished operator. 

M. Larrey blamed the operator for attempting so considerable an opera- 
tion without previous consultation with his colleagues. He deemed the 
attempted removal of the tumour itself of questionable propriety, inasmuch 
as it was proved to the satisfaction of the surgeon to be encephaloid in its 
character, and hence, aside from the difficulties of its entire extirpation, it 
was not only liable to prove fatal, either by hemorrhage, extension of the 
disease, suppuration, resorption, gangrene, cancerous infection, but by nerv- 
ous exhaustion, as the result proved, the patient having died during the 
following night. 

M. Chassaignac replied that while his conduct might be censurable ; in 
the light of science and humanity the operation was justifiable. The patient 
was young and apparently healthy, and the disease, as proved by explora- 
tions, was of a rapidly fatal character. At first he proposed ligation of 



I860.] Smith, Deligation of the Primitive Iliac Artery. 39 

the femoral, but the fear of hemorrhage induced him to prefer ligation of 
the primitive iliac, especially as this latter operation has proved successful 
in two of six cases. It answered the end proposed in this case by prevent- 
ing hemorrhage. He did not think the seat of the tumour contra-indicated 
the operation, nor could the fatal issue of the case have been foretold if we 
reflect that patients survive the ligature of both carotids. 

M. Robert agreed with Larrey as to the impropriety of attempting the 
removal of a tumour in the situation of this — encephaloid in its character, 
and probably extending into the pelvic cavity. A fatal termination was to 
have been expected from this operation; but Chassaignac still further com- 
promised the life of his patient, by superadding another grave operation ; 
while he acknowledged the courage of his colleague, he could but recognize 
the fact that he had overstepped the limits of his art. 

M. Chassaignac denied the possibility of confounding the tumour with 
an osteo-sarcoma, for the most minute examination had been made in regard 
to this point. He was satisfied from his examination that if the tumour 
did penetrate into the pelvis, it was but slight. Though he did not approve 
the practice of removing tumours attached to bone, still such attachment 
was not an absolute contra-indication. The vascularity of the tumour, and 
the absence of hemorrhage during the operation, prove the advantage of 
the preventive ligature. 

M. Grosselin did not consider tumours, situated as in this case, beyond 
the reach of art. His objection to the procedure lay against the preventive * 
ligature applied to the primitive iliac. These ligatures are generally con- 
sidered hurtful, and I do not approve them, except the vessels which may 
be involved are situated deeply and beyond the reach of the surgeon ; but 
in this case the vessels involved in the operation were under the control of 
the surgeon ; nor has he anything to fear from hemorrhage in the removal 
of tumours of this kind, for the vessels approach from certain fixed points 
and can be readily ligated. Strictly speaking, I approve then a provisional 
ligature only when it is not in itself dangerous ; otherwise, does it not 
expose the patient not only to all the chances of a grave operation to pre- 
vent a primary hemorrhage, but also to the consequences of a secondary 
hemorrhage? 

M. Chassaignac replied that the objections of M. Gosselin were con- 
sidered before the operation, and still he concluded to ligate the common 
iliac artery. The tumour, so vascular, might receive vessels in its entire 
circumference, and especially might not be encysted. It was also deeply 
situated, its extirpation difficult, its degree of penetration into the pelvic 
cavity undetermined, a strong probability that the tumour was nourished 
by numerous inaccessible branches of the internal iliac, for these reasons he 
preferred ligation of the primitive iliac before attempting the removal of 
the tumour. 

M. Maisonneuve did not regard this operation in the same light as his 
colleagues. The surgeon ought to regard only the interests of his patient. 
If the victim of a quickly fatal disease, the surgeon ought not to refuse the 
resources of the art, however slight they may be. Chassaignac's patient 
was young and vigorous, and his disease fatal. He gave him the chance 
of help in his power, and he did well. Doubtless he was upon the limits 
of the art, of the possible ; but the operation itself proves that he did not 
overpass those limits. It was completed without involving any important 
organ. It terminated unfortunately ; but how often does disarticulation of 
the femur have a fatal termination, and yet the surgeon does not recoil from 



40 



Smith, Deligation of the Primitive Iliac Artery. [July 



this operation. As to ligature of the primitive iliac, he shared the views 
of M. Gosselin ; but to decide definitely upon this point, it would have been 
necessary to see the patient. 

M. Huguier regretted that M. Chassaignac had not given the presumed 
causes of death. It could be referred in this case to several causes ; but it 
was important to know if the action of chloroform, which was long-con- 
tinued, could not be assigned. The same may be alleged of the exhaustion 
of the nervous system. Ligation of the primitive iliac, by instantly sus- 
pending the circulation of that limb, might have caused consecutively pul- 
monary, cerebral, or cardiac congestions. 

M. Chassaignac stated that the operation lasted half an hour, during 
which time the patient was under the influence of chloroform, and he was 
disposed to think that the action of this agent had something to do with 
his death ; still he did not desire to evade the full responsibility of the 
operation, by assigning this as a cause of death. 

M. Forget opposed the views of M. Maisonneuve, contending that the 
judicious surgeon would not compromise his art by exercising it in a case 
so hopeless. The principles of surgery are not of unlimited application, 
and it is necessary to guard against their abuse. The limits of the tumour 
being unknown, the propriety of the operation became questionable. Mai- 
sonneuve quotes the case of disarticulation of the thigh by Sanson, and 
though it proved fatal a few minutes after the operation, alleges that the 
procedure is still considered justifiable ; but the case proves the very oppo- 
site of the doctrine supported by Maisonneuve, for here we have superadded 
to an operation more severe than Sanson's, an operation of the greatest 
gravity. 

General Considerations. — A review of the preceding tables gives the fol- 
lowing facts and conclusions : — 

Sex. — Of thirty -two cases of ligation of the primitive iliac artery, twenty- 
seven occurred in males, three in females, two sex not given. The great 
preponderance of males over females is undoubtedly owing to the greater 
exposure of the former to the exciting causes of aneurism, as well as to 
local injuries. 

Age. — The ages of the patients are seen to vary from six weeks (Bushe) 
to fifty -nine years (Meier), as follows: — 

Under 1 year . . .1 Between 30 and 40 .10 
Between 1 and 10 . .1 " 40 " 50 . .6 

20 " 30 . .6 " 50 " 60 . . 3 

Disease. — In twenty-four cases, aneurism directly or indirectly led to 
the operation. These tumours involved the following arteries : right ex- 
ternal iliac, eleven ; left external iliac, seven ; femoral, one ; gluteal, two ; 
varicose, one; not given, two. In four cases the tumour was malignant, 
though simulating aneurism. The liability of the right external iliac artery 
to aneurism, as here shown, is very much greater than the left. In the 
cases of malignant disease it will be seen that the right and left side were 
the seat of disease in the same number of cases. 

Artery ligated. — In seventeen cases the right primitive iliac was ligated, 
and of these three were successful ; in thirteen the left primitive was ligated, 
of which one recovered. 



I860.] Smith, Deligation of the Primitive Iliac Artery. 41 

Mortality. — Of thirty-two cases, twenty-five died, and seven recovered, 
being a mortality of about Y8J per cent; the mortality after ligation of 
the external iliac is about 28 per cent. 

The success of this operation is evidently greatly overrated by our best 
authorities. Erichsen remarks, "When we look at the depth at which this 
artery is situated, its great size, and proximity to the centre of the circula- 
tion, and consider the force with which the blood rushes through it, we 
cannot but be struck with the success which has attended its ligature. Of 
seventeen cases in which it has been tried, nine were cured and eight died." 
From what source he obtained his statistics I do not know; if correct, he 
has had access to cases which I have failed to reach. Prof. Gross takes a 
still more favourable view of this operation. He says (System of Surgery, 
vol. i. p. 940), "The artery has since been secured in about twenty cases, 
of which nearly two-thirds have terminated successfully." 

The statistics of this operation, which are herein embraced, give very 
different conclusions, and will serve to place it among the most unsuccessful 
procedures in operative surgery. 

It is worthy of note that, according to these statistics, since the year 
1845, the date of Mr. Stanley's operation, no successful case of ligation of 
the primitive iliac has been reported, though during that period of fifteen 
years the operation has been performed no less than fifteen times. It will 
be remembered that this period embraces the entire history of anaesthesia, 
and it is important to inquire as to the influence of these agents in pro- 
ducing this excessive mortality. 



Nine Cases of Ligation of the Common Iliac Artery in which Anaesthetics were 
administered during the Operation. 



No. 


Operator. 


Injury or disease. 


Date of death. 


Cause of death. 


1 


Chassaignac 


Removal of tumour 


16 hours 


Shock of operation 


2 


Jones 


Aneurism 


15 th day 


Erysipelas 


3 


Uhde 


Aneurism 


4th day 


4 


Van Buren 


Aneurism 


4th day 


Suppuration of sac 


5 


Edwards 


Hemorrhage 


25th day 


Hemorrhage 


6 


Meier 


Malignant disease 


12th day 


Gangrene of leg 


7 


Buck 


Hemorrhage 


17th day 


Hemorrhage 


8 


Stephen Smith 


Aneurism 


48th day 


Hemorrhage 


9 


Parker 


Hemorrhage 


10 hours 


Exhaustion 



The case of M. Chassaignac is the only one in this table which would 
seem to warrant the supposition that the anaesthetic agent determined the 
fatal result. But the operation itself was in this case of sufficient severity 
to have led to a fatal issue, independently of any other agency; and although 
the chloroform, so long continued, doubtless added to the prostration of 
the patient, there is no evidence that of itself it was the producing cause 
of death. Neither the operator, or the members of the society before whom 
he narrated the case, with one exception, seem to have attributed to the 



42 



Smith, Deligation of the Primitive Iliac Artery. [July 



anaesthetic the unfavourable issue which followed. To show further how 
little probability there is that the excessive mortality attending this opera- 
tion during the last fifteen years is due to the use of anaesthetic agents, we 
may compare with the cases just adduced, in which chloroform was used, 
the nine fatal cases - which occurred previously to the date at which these 
agents were employed. It will be seen also that the diseases or accidents 
for which the operation was undertaken were the same for each period, 
making the comparison still more accurate. 



Nine Cases of Deligation of the Primitive Iliac Artery in luliich Ancestlxetics 

were not used. 



m 


Operator. 


Disease. 


Date of death. 


Cause of death. 


i 


Gibson 


Hemorrhage 


13th day 


Hemorrhage 


2 


Crampton 


Aneurism 


10th day 


Hemorrhage 


3 


Liston 


Hemorrhage 


24 hours 


Exhaustion 


4 


Grarviso 


Aneurism 


4 hours 




5 


Syme 


Aneurism 


4th day 


G-angrene of leg 


6 


Bushe 


Aneurism 


37th day 


Abscess of knee 


7 


Post 


Hemorrhage 


24 hours 


Exhaustion 


8 


Pirogoff 


Hemorrhage 


14th day 


Hemorrhage 


9 


Stanley 

- 


Malignant disease 


3d day 


Exhaustion 



The extreme dates of death after the operation in the first table are six- 
teen hours and forty-eight days, the average period of death was fourteen 
and a half days. The extreme dates of death in the second table were four 
hours and thirty-seven days, the average being about nine days. It would 
appear, therefore, that those patients who were operated upon while under 
the influence of an anaesthetic lived longer, and consequently were less 
affected by the operation itself, than those who were not thus treated. 

The Material of the Ligature. — In all the cases except two, as far as 
we can ascertain, the common silk ligature was employed. These excep- 
tional cases deserve a passing notice. 

Crampton employed a ligature made of catgut, which escaped from the 
artery on the eighth day, and on the tenth his patient died suddenly from 
hemorrhage. On dissection the important fact seems to have been clearly 
established, that the ligature "had been dissolved by the heat and moisture 
of the wound, and thrown off before the obstruction of the artery, or the 
coagulation of the blood in the aneurismal sac, had been completed. It 
further appeared that the dissolution of the ligature had caused a small 
abscess to form in the place which it occupied." At the period of Cramp- 
ton's operation the catgut ligature, first recommended by Mr. Young in 
1813, was frequently employed, and with very satisfactory results. It was 
preferred on account of its unirritating properties, and its capacity for dis- 
solution after it has subserved the purposes for which it was applied to the 
artery. Prof. Porta, who experimented largely with catgut ligatures, found 
that soon after this ligature was applied to the artery it became surrounded 



I860.] Smith, Deligation of the Primitive Iliac Artery. 43 

with plastic lymph, which, becoming organized, formed either a cellular 
web, or a ligamentous substance, or suppurative inflammation was esta- 
blished, resulting in a circumscribed abscess. The latter occurred in only 
twenty-six of two hundred and thirty-six experiments. It occurred also in 
Crampton's case, and proved fatal. It is stated that the ligature dissolved 
and separated on the eighth day in Crampton's case. Prof. Porta applied 
the catgut ligature eighty times, and in thirty-three instances it disappeared, 
the earliest date of its disappearance being thirty days, the latest three 
years. It would seem, therefore, that the unfortunate result in Crampton's 
case was quite exceptional, both in the formation of an abscess and the 
early destruction of the ligature. 

Stone employed silver wire as a ligature to arteries for the first time. 
In its application he did not tighten it sufficiently to lacerate the coats of 
the artery, but merely to interrupt the current of blood. The operator 
selected the silver wire under the impression that for the cure of aneurism 
it is only required to arrest the current of blood, and that for the obliteration 
of arteries it is not necessary to cause a division of their coats. The silver 
wire, therefore, tightly applied will not cause ulceration, and hence answers 
perfectly the design of the operator, by arresting the current of blood and 
producing a gradual obliteration of the artery. The death of the patient, 
and the failure to obtain a post-mortem examination, have left these most 
important questions undecided ; but it can scarcely be doubted that the 
silver wire will prove the most reliable form of ligature, especially upon 
larger arteries, in which it is most important that the several coats should 
preserve their integrity much longer than is ordinarily the case with the 
silk ligature tightly drawn, in order that no lesion shall occur until the 
process of obliteration is so far completed as to resist the arterial propul- 
sion. This view is sustained by reference to the date of the separation of 
the ligature, where it will be seen that in the majority of cases of secondary 
hemorrhage, after ligation of the primitive iliac artery, the ligature sepa- 
rated much earlier than in the cases of recovery. 

Separation of the Ligature. — The date of the separation of the ligature 
is given in twelve cases, as follows : — 



Xo. 


Operator. 


Date of separation. 


Eesult. 


Cause of death. 


1 


Mott 


18th day 


Recovered 




2 


Crampton 


8th day 


Died 


Hemorrhage 


3 


Guthrie 


26th day 


Recovered 


4 


Salomon 


32d day 


Recovered 




5 


Bushe 


13th day 


Died 


Abscess of knee 


6 


Deguise 


16th day 


Recovered 




7 


Peace 


32d day 


Recovered 




8 


Hey 


28th day 


Recovered 




9 


Garviso 


36th day 


Recovered 




10 


Edwards 


16th day 


Died 


Hemorrhage 


11 


Buck 


13th day 


Died 


Hemorrhage 


12 


Stephen Smith 


36th day 


Died 


Hemorrhage 



44 Smith, Deligation of the Primitive Iliac Artery. [July 

The longest period of retention of the ligature was thirty-six days, and 
the shortest eight days ; the average being nearly 23 days. An examina- 
tion of fifty cases of deligation of the external iliac artery gives an average 
of twenty-two days for separation of the ligature. An important distinc- 
tion may be made between the successful and unsuccessful cases, in regard 
to the period of the separation of the ligature. It will be noticed that in 
the successful cases the ligature was retained much longer than in the fatal 
cases. For the former class the average period of retention of the ligature 
is twenty-four days, while for the latter it is but about seventeen days, thus 
leading to the important inference that the early separation of the ligature 
is an indication of danger from hemorrhage. 



Nine Gases in which the Peritoneum was wounded during the Operation. 



No. 


Operator. 


Peritoneum. 


Result. 


Cause of death. 


1 


Gibson 


Freely opened 


Died 


Hemorrhage ; peritonitis 


2 


Guthrie 


Wounded twice 


Cured 




3 


Stevens 


Freely opened 


Died 




4 


Garviso 


Freely opened 


Died 


Exhaustion 


5 


Pirogoff 


Wounded twice 


Died 


Hemorrhage ; peritonitis 


6 


Post 


Freely opened 


Died 


Exhaustion 


7 


Buck 


Wounded twice 


Died 


Hemorrhage 


8 


Stone 


Lacerated 


Died 


Dysentery 


9 


Goldsmith 


Freely opened 


Died 


Exhaustion 



Of these nine cases in which the peritoneum was wounded, but one 
recovered. In four the wounds were slight (Guthrie, Pirogoff, Buck, 
Stone), of which one recovered. Of the remaining three, one had the local 
appearances of peritonitis (Pirogoff), the others had none (Buck, Stone). 
Of the five cases in which the peritoneum was freely opened, three died 
within twenty-four hours (Garviso, Post); one lived two days, and had 
local peritonitis (Stevens) ; one lived five days, no peritonitis (Goldsmith) ; 
one lived thirteen days, having severe peritonitis (Gibson). 

It does not, however, appear certain that in any case a wound of the 
peritoneum has caused the fatal result, although it cannot be doubted that 
it is a serious complication, and one that should be carefully avoided. In 
the four cases in which it was freely opened the operation was performed 
without any special effort to guard this membrane. In the remaining cases 
the wound was accidental, and every precaution was taken to prevent its 
occurrence. 

The Operation. — It will be seen by reference to the operative procedure 
in the several cases reported that two principal methods have, with various 
modifications, been adopted, viz., 1st, deligation of the artery external to 
the peritoneum ; 2d, through the peritoneum, or, as Malgaigne has well 
entitled these methods, incision extra-peritoneale and incision peritoneale. 
To accomplish the first operation two methods have been pursued, the first 
being a modification of Abernethy's operation in ligation of the external 



I860.] Smith, Delegation of the Primitive Hiac Artery. 



4-3 



iliac artery, viz., an incision in the course of the artery; and the second 
being a modification of Cooper's operation upon the same artery, viz., a 
curved incision above and parallel with Poupart's ligament. The former 
method has been adopted only in cases which did not seem to the operator 
to admit of the other procedure (Gibson, Garviso, Post, Buck). 

The second method has been variously modified by the different surgeons 
who have practised it. It has been described by Tidal under two divisions: 
1st. incision parallel with Poupart-s ligament; 2d, incision parallel with 
the linea semilunaris. Linhart gives the following incisions as types of 
the different methods : 1st, a curved incision from the anterior end of the 
last rib to the anterior superior spinous process (Crampton) ; 2d, incision 
parallel with the linea semilunaris ; 3d, incision from a little above the 
anterior superior spine in the direction of the umbilicus, but extending only 
to the sheath of the rectus (Dumricher). A better subdivision, however, 
of this operation would be into the high and low incision, a line drawn from 
the anterior superior spinous process to the umbilicus, being the line of 
division accordingly as the incision extends above or below this point. 

Mott was the first to perform the low operation, and still advocates his 
original operation. He commenced his incision just above the external 
abdominal ring, half an inch above Poupart's ligament, and terminated it 
a little beyond the anterior superior spine of the ilium, the extent of the 
incision being five inches. The peritoneum was raised by entering the 
external ring. The difiiculties which he encountered were, first, division of 
the circumflex iliac artery; second, inability to reach the primitive iliac 
with ut enlarging the wound upward to the extent of three inches. 

Crampton was the next operator, and first performed the high operation, 
in the following manner : The incision began at the extremity of the last 
false rib. and terminated at the anterior superior spine of the os ilium, 
haying a curvilinear direction, and being nearly in a line with the crista 
ilii. The operation is described as "an exceedingly easy operation," and 
was completed in twenty minutes, without any complication whatever. 

The modifications of these two very different incisions are numerous, 
and, with three or four exceptions, unimportant. These exceptional cases 
are as follows : — 

Guthrie says, "I may state that if the incision is made in the side, from 
the ribs to the ilium, in a straight line, the greatest possible difficulty is 
experienced in turning over the peritoneum, so as to place your finger upon 
the last vertebra ; but if a diagonal inclination be given towards the rectus 
muscle, not opening its sheath so as to expose it, but carrying the incision 
fully up to that part, then there is room to turn over the peritoneum, with 
its contents, so as to get at the artery." 

Dumricher made an incision from just above the anterior superior spine 
upwards and inwards towards the umbilicus nearly to the sheath of the 
rectus muscle, and Linhart speaks of this method as preferable to all 
others. 



46 



Sawyer, Carcinoma of Uterus. 



[July 



Salomon, believing that Crampton's operation rendered the exposure of 
the artery difficult, and the detachment of peritoneum unnecessarily exten- 
sive, made his incision parallel to the internal epigastric artery, commenchig 
an inch within the anterior superior spinous process, and terminating within 
an inch of the last false rib. 

Hey modified the high operation by making "an angular continuation 
an inch and a half in length" outwards ; but his description is so indefinite 
as to leave us in doubt as to the value of this extension of the first 
incision. 

Before proceeding to the operation which it fell to me to perform, I put 
these various methods to the test upon the cadaver, and after repeated trials 
came to the conclusion that the following incision gave the most direct and 
easy access to the artery: Commence the incision just anterior to the 
extremity of the second false rib (eleventh) and terminate it just above 
the internal ring by a sharp curve inward of one inch ; this incision will 
be about seven inches in length, and will pass about an inch and a half 
within the anterior superior spinous process ; the curve at the lower extre- 
mity will allow the most perfect freedom in the elevation of the peritoneum, 
and the complete exposure of the artery. 

The second method by incision of the peritoneum was first practised by 
Gibson, and subsequently by Garviso, Post, and Goldsmith. It is needless 
to comment upon the propriety of this procedure in ordinary cases. 

The following caution, given by Guthrie, in regard to raising the peri- 
toneum, is worthy of attention : "There is a point here of great import- 
ance to recollect, and it is, that the peritoneum must be raised over without 
the hand being pushed back towards the posterior wall of the abdomen but 
as little as can be avoided ; for there is some fat usually at that part, if 
there be any to be found in the body, and behind which you are very apt to 
get in performing the operation instead of going in the front ; and if you 
do, it leads to the under edge of the psoas muscle instead of the upper, and 
renders the operation much more difficult." 



Art. II. — Carcinoma of Ute?ms : Extirpation. 
By A. F. Sawyer, M. D., San Francisco. 

Mrs. S., aged forty-three years, arrived here from New Orleans, in 1852. 
She was rather spare in habit, yet with a fair muscular development, and 
of a nervous, sanguine temperament. She was married in her seventeenth 
year, and previous to her coming to California had borne four children. 
There had always been long intervals between her conceptions. She has 
never miscarried. 



< 



I860.] Sawyer, Carcinoma of Uterus. 4T 

The tumour was first noticed in her abdomen, in January, 1849, when 
she was recovering from her fourth confinement, after the birth of a healthy 
and mature child. 

My attention was called to her case in the early part of 1855, at which 
time there was found a well-defined tumour, of about the size of the two 
fists, similar in form to the uterus, occupying the median line of the abdomen, 
and when she was in an upright position sinking low down into the cavity 
of the pelvis. The form and location of the tumour, together with the 
general indications of the case arrived at from an examination of the rectum 
and vagina, especially the existence of ballottement, led to the conclusion 
that it was connected with the uterus, probably of a fibrous nature, and 
developed at the expense of the uterine cavity; for, otherwise, in the en- 
larged condition of the uterus its symmetrical shape could not be accounted 
for. 

Her catamenia had never been regular since her last confinement ; some- 
times scanty, sometimes very profuse, occurring at indefinite intervals of 
from three to six weeks, and accompanied with strong bearing-clown pains. 
At other times she suffered but little inconvenience, excepting what resulted 
mechanically from the position 1 and weight of the tumour. 

On the 12th of October, 1856, she was delivered of a healthy child at 
full term. During the early period of gestation it was uncertain whether 
the growth of the uterus came from pregnancy, or was to be attributed to 
an increased activity in the development of the tumour itself. Toward the 
close of gestation the placental murmur and the sound of the foetal heart 
made her pregnancy certain. Without these signs, as the movements of 
the foetus were never distinct, and as there was a repeated recurrence of a 
sanguineous discharge from the vagina, the diagnosis would have been 
materially obscured. As pregnancy advanced, however, a double tumour 
could be felt within the abdomen, and plainly observed by the eye after the 
abdominal walls became distended over the gradually enlarging uterus — the 
womb occupying the left side and crowding the tumour to the upper and 
right side of the abdominal cavity; also, the condition of pregnancy seemed 
to stimulate the growth of the tumour, as at the end of gestation it had 
become at least one-half as large again as when first examined. 

Her labour went on naturally and without accident, and she made a 
prompt recovery. After labour the uterus could no longer be felt, and the 
tumour resumed its former position in the pelvic cavity. 

With this enlarged history of the case we were compelled to abandon 
the idea that the tumour was uterine, and were rather disposed to consider 
it as ovarian disease. For it was not within the limits of reasonable pro- 
bability that the uterus, granting it to have been thus extensively involved 
in structural disease, could have sustained the nutrition of a foetus up to its 
full term, even if conception were possible. 

There was no indication of attachment, for the tumour could be easily 



48 



Sawyer, Carcinoma of Uterus. 



[July 



elevated, and moved to and fro in the pelvic cavity. There was no marked 
tenderness on pressure. It had a regular smooth outline without nodosities, 
and the sensation to the hand was that decidedly of a solid growth. This, 
with the absence of elasticity or fluctuation, seemed to indicate that it was 
not encysted disease. 

From her last confinement up to the date of the operation, June 8, 1859, 
the tumour gained rapidly in size, producing almost insupportable sensa- 
tions of a dragging weight, with now and then acute lancinating pains 
referred to the tumour, and extending down into the privates and thighs, 
and the patient was rapidly failing in physical vigour and strength. Her 
sufferings finally increased to such an extent that, notwithstanding a full 
explanation of the dangers attending operations of this character and 
magnitude, she became resolutely determined to undergo every hazard to 
accomplish its removal. 

The patient being placed under the influence of sulphuric ether, an inci- 
sion was made into the peritoneal cavity, extending from a little above the 
umbilicus to the pubis, in the direction of the linea alba. The true nature 
of the disease was then apparent, it being a large solid growth, without 
adhesions, embedded in the parietes, and resembling an enormous hyper- 
trophy of the uterus. The ovaries rested on either margin of the tumour, 
the left natural in appearance, and the right considerably atrophied. A 
large curved needle, armed with a strong ligature, was then passed through 
the textures below the cervix uteri, the ligatures made secure, and the 
tumour amputated above the ligatures. The free ends of the ligature were 
then brought out of the abdominal wound, which was immediately closed 
by sutures and adhesive plaster. 

Description of the Tumour. — The tumour had an exact resemblance to 
the uterus in form, measuring 9 J inches in its long and 1 J inches in its short 
diameter, and about 5 inches through from side to side. Its surface was 
perfectly smooth, and covered with peritoneal membrane ; a large number 
of dilated bloodvessels ramified over the exterior of the tumour, becoming 
finally concentrated into the vessels of the broad ligaments. The mass 
removed weighed pounds. 

A section of the tumour showed that it had its origin at the fundus of 
the uterus. At least the greatest bulk of the tumour was found at the 
fundus, thence extending downward over the anterior face and right margin 
of this organ. The posterior walls and left border were but little encroached 
upon by the disease ; the muscular coat being of the natural thickness. 

From without inwards the following textures were noted. 1st. Perito- 
neum. 2d. The uterine parietes, about two lines in thickness. Then a 
cyst wall of cartilaginous structure, crowded with well-defined plates of 
amorphous calcareous deposit, inclosing the softer parts of the tumour, 
which last had a partially lobulated appearance, the lobules possessing 
different characteristics. Some being of a grayish colour, with but little 



I860,] Sawyer, Carcinoma of Uterus. 49 

consistency, resembling cerebriform fungus ; others much firmer in struc- 
ture, of reddish appearance, with bands of white cartilaginous fibre travers- 
ing them in different directions. Quite large calcareous particles were 
distributed through the denser portion of the tumour. Indeed, a section 
of any portion of the tumour gave a gritty feel to the knife. Lastly, the 
true muscular texture of the uterus, about three lines in thickness, with the 
mucous membrane of the uterine cavity, which presented small patches of 
ecchymosis on its inner surface. 

From this description it will be seen that the tumour rested within the 
muscular parietes of the uterus. Splitting then, as it were, in its develop- 
ment, the outer muscular layers forming its external covering, and the inner 
layers preventing the encroachment of the tumour upon the uterine cavity. 
The os and canal of the cervix were pervious, as also the left Fallopian tube. 
The right was pervious only about three lines from the uterine orifice. 

The patient progressed well up to the fourth day after the operation. 
There was but little distension of the abdomen, and not marked tenderness ; 
not much thirst ; the pulse varying from 80 to 90. The bladder was kept 
empty by the catheter. On the third day a trifling discharge of healthy 
pus was noticed from the vagina. Small doses of calomel and opium were 
prescribed as a prophylactic, and to quiet the nervous system. 

On the evening of the fourth day strong rigors supervened, and the 4 
patient's condition changed 1 rapidly for the worse, the stomach rejecting 
everything presented to it, whether of a liquid or solid form. The lower 
portion of the abdomen became swollen and tender, which soon extended 
itself over the entire peritoneal cavity. The pulse rose to 140, and the 
countenance of the patient assumed an anxious and distressed look. The 
healthy suppuration from the vagina gave way to an excessively fetid and 
sanious discharge. These symptoms became steadily more aggravated until 
her death, which occurred on the sixth day after the operation. 

In the way of treatment external irritants, as turpentine and emollient 
fomentations, were applied over the abdomen, without effect. Internal 
remedies were rejected as soon as presented. Inhalations of sulphuric ether 
afforded some relief to the distress of the patient. Her most painful sensa- 
tion was a tenesmus, and uncontrollable bearing down of the rectum. A long 
flexible catheter was introduced into the gut without benefit. Mucilaginous 
injections, combined with morphia and lac assafcetida, gave some palliation 
to these symptoms. 

Post-mortem examination six hours after death. — The wound of the 
abdomen had united in its whole extent, excepting at the point which had 
afforded escape for the ligature. There was considerable but not extraor- 
dinary inflation of the peritoneal cavity. The whole intestinal track, in- 
cluding the stomach, had a congested and inflamed appearance. Several 
small particles of ecchymosis were observed near the pyloric orifice of the 
stomach. The mucous coat of the rectum was deeply engorged and some- 
what softened. About ^x of a dark sanguineous fluid, mixed with clots, 
No. LXXIX.— July 1860. 4 



50 



Sawyer, Carcinoma of Uterus. 



[July 



occupied the dependent portion of the peritoneal cavity. Bladder contracted, 
without urine. Yagina softened and sloughy. On examining the stump 
of the wound the ligatures were found partially loosened from their attach- 
ments by ulceration, and its free end covered by a small, half decomposed 
clot, which, when removed, showed the patent mouths of bloodvessels. 

There is little doubt that the remote cause of death was from secondary 
hemorrhage, which probably set in on the fourth day after the operation. 
The compression on the vessels becoming relaxed by the partial separation 
of the ligatures, before the plastic powers of nature had closed the arteries 
firmly enough to withstand the ordinary force of the circulation. The 
proximate cause of death was connected with the decomposition of the clot 
within the cavity of the peritoneum, and which led to the train of symp- 
toms that afterward supervened, and could not be controlled. 

This case presents several points of marked interest. It will be observed 
that our original diagnosis, and as afterward proved to be the correct inter- 
pretation, was that the tumour involved structurally the uterus itself. It 
is to be recollected that the patient was under observation for nearly a year 
before her last pregnancy occurred ; and during this time, when we had 
every satisfactory evidence that the tumour was not attributable to preg- 
nancy, the existence of ballottement seemed to establish our opinion conclu- 
sively. The sensation of ballottement indicates a weighty uterus, without 
determining the cause which has led to its increased weight. This must be 
settled by the collateral history of the case ; and when the circumstances 
are such as to preclude the probability of pregnancy, it becomes a very 
important diagnostic sign for predicating the existence of uterine tumour. 
If the cavity of the uterus admits of examination by the uterine sound, of 
course the character of the tumour is more plainly fixed, as in eliminating 
the presence of polypoid growths, or of fluid within the uterine cavity, which 
may lead to such a distension of that organ as to give fully the sensation 
of ballottement. A case of the latter description has fallen under our obser- 
vation, and the simple introduction of a fine pointed gum-elastic bougie 
sufficed for the cure of the case, by affording evacuation to a considerable 
quantity of a fetid serous fluid. 

In this" instance, although the uterine canal was pervious to the sound, 
it was wrongly supposed that the cavity of the uterus had become dilated 
by the gradual increase of the tumour, as may occur from unnatural as well 
as from natural causes. 

Not the least remarkable feature in her case was that she had been able 
to carry her fetus to the full term, when such a large and unyielding mor- 
bid mass had been located within the muscular parietes of the womb. In 
short, we were unwilling to admit the presumption of pregnancy, until all 
doubt was removed by the sound of the foetal heart. When the abdomen 
became fully distended, as gestation advanced, the tumour appeared to the 
eye, and, indeed, as could be easily felt by the hand, entirely distinct from 
the gravid womb, so that we were forced to the conclusion that the tumour 



I860.] 



Sawyer, Carcinoma of Uterus. 



51 



was disconnected with the body of the uteres, and that the ballottement at 
first noted arose from the close anatomical relations of the tumour to the 
uterus, probably resting in juxtaposition with it, so as to readily convey 
by transmission the sense of ballottement to the touch. 

There are abundant cases recorded, where it is demonstrated that the 
form and anatomical location of the tumour do not always conclusively 
indicate either the nature of the disease, or in what organs it may have 
specially originated. Ovarian tumours have not unfrequently simulated 
uterine tumours, and vice versa. We have known cancerous degeneration 
of the kidney mistaken for ovarian disease, and yet scarcely a doubt could 
exist that it was not ovarian prior to the operation. A successful case 
occurred here in the hands of an old and experienced surgeon, who made 
abdominal section for ovarian disease. The tumour was found, however, 
to be a large fibrous tumour of the uterus, weighing several pounds, which 
was separated from its pedicle. The patient made a complete recovery 
from the operation. 

In the present instance it is worth remarking that the functional power 
of the uterus was curiously sustained, where the patient was able to bear a 
mature child, notwithstanding the existence of an immense foreign growth^ 
imbedded, as it were, in the muscular parietes of the womb. In this con- 
nection we would call attention to the healthy appearance of the left ovary, 
as contrasted with the shrunken and atrophied condition of the right, asso- 
ciated with the complete obliteration of the corresponding Fallopian tube. 

We append the following list of cases of abdominal section, with results 
— a total of eleven cases, which probably includes all the operations of this 
character made in California : — 

Seven cases of ovarian disease, of which six terminated fatally. In three 
of the seven cases the wound was closed without attempt at removal of the 
tumour, on account of unusual complications. In one case the contents of 
the cyst were purulent. In the seventh case (Dr. Nelson's) the patient 
made a perfect recovery, although the case appeared unfavourable, from 
extensive adhesions. One case of Cesarean operation (Dr. Cooper) suc- 
cessful. One case of fibrous tumour of uterus (Dr. Nelson) successful. 
One case of carcinoma of uterus (the case here reported) fatal. One case 
of fungus nematodes of kidney, fatal. 

These cases have generally been in the hands of fully competent and 
experienced surgeons ; and the fatality, as far as ovarian disease is conr 
cerned (six out of seven cases), compares very unfavourably with the pub- 
lished statistical accounts of the success of this operation. A great deal 
has been said and written about the proper selection of cases for operative 
procedure. Experience, however, shows that the most skilful surgeons are 
likely to be in error in their selection of cases for operation, which before- 
hand, in a diagnostic point of view, may have afforded the most promising 
expectations of radical success. Besides, we have to consider, whatever 



52 



Kinloch, Reducible Inguinal Hernia. m [July 



may have been the previous history of this class of cases, whether they 
have been under the treatment of empirics or the enlightened medical prac- 
titioner, when it comes to the question of an operation. Men of acknow- 
ledged ability and reputation in surgery are solicited to take charge of the 
patient ; and do they always furnish a report of their unsuccessful cases as 
well as of their successful ? For our own part we are satisfied that the 
statistics of ovariotomy are entirely unreliable, because but a feeble fraction 
of the fatal cases are given to the public ; whilst there is not a single suc- 
cessful operation that does not find its way, either directly or indirectly, 
into some of the medical periodicals of the day. 



Art. III. — Tivo Cases of Reducible Inguinal Hernia operated on for 
the Radical Cure. By R. A. Kinloch, M. D., Surgeon of the Roper 
Hospital, Charleston, S. C. (With five wood-cuts.) 

Case I. Hamber, a native of Germany, set. 32, basket-maker, was admit- 
ted into the Roper Hospital January 1, 1859, labouring under oblique in- 
guinal hernia on the left side, occasioned by heavy lifting two months 
previously. Has a weakly appearance, with sallow complexion, and has 
long suffered from dyspepsia; but entered the hospital to be cured, if possi- 
ble, of hernia. It was thought advisable first to improve his general health, 
and with this view he was treated with occasional mercurial laxatives, 
alkalies, and bitter tonics, together with generous diet and a liberal allow- 
ance of porter. 

January 22. Patient's condition so much improved that he was con- 
sidered ready for operation. Being recumbent, and fully chloroformed, the 
operation was practised as follows : "A portion of the scrotal integument 
was invaginated and pushed well up into the inguinal canal with the index 
finger of the left hand. A strong and slightly curved needle, fixed to a 
handle and armed with a double suture of annealed iron wire (No. 32) of 
proper length, was passed up the invaginated integument, along the finger 
as a guide, to the internal ring, and made to perforate all the abdominal 
structures in front of the inguinal canal. The wire was then liberated from 
the eye of the needle by an assistant, and the needle withdrawn. A second, 
third, fourth, fifth, and sixth puncture was then successively made in the 
same way as the first, and through each perforation was carried a double 
wire suture. These perforations were so placed that there were three to 
the left and three to the right, so that the upper extremities of the sutures 
passed through the antero-lateral walls of the inguinal canal ; each suture 
was separated from its neighbour of the same side by the distance of a third 
of an -inch, and from its neighbour of the opposite side by the distance of 



I860.] 



Kinloch, Reducible Inguinal Hernia. 



53 



half an inch or more. But one extremity of each of the double wire sutures, 
previous to the beginning of the operation, had been securely attached, by 
means of transfixion and knotting, to a plug of India-rubber, two inches 
long, and about the thickness and shape of the thumb — this form had been 
rudely given to the plug by trimming with the scissors. The index finger 
of the left hand was now withdrawn from the canal, and the plug of India- 
rubber was made to take its place, by carefully pulling the upper extremi- 
ties of the six wire sutures, making greater traction upon one or the other 
suture from time to time, until the plug was snugly lodged in the inguinal 
canal. The operation was completed by twisting the sutures of either side 
separately over a small quill or strip of India-rubber, an inch and a half 
long. Thus, the India-rubber plug, and not the sutures alone, preserved 
the invagination of the scrotal integument, and kept it in contact with the 
contour of the canal. After the effects of the chloroform had passed off, 
patient was depressed and required a little stimulus. He was put to bed 
and ordered R. — Tinct. opii 3j- Half to be taken at once, and the 
remainder at bedtime. 

23d. Patient had suffered considerable pain for several hours after the 
operation, but had finally slept well at night. To day he makes no com- 
plaint. Pulse normal. R. — Tinct. opii 3 SS three times a day. Diet, 
gruel, and bread and tea. 

2ith. Has had some pain about the part operated on ; slight inflamma- 
tory blush now about the groin and upper part of scrotum ; abdomen a little 
puffed; bowels constipated; pulse 100. B. — Pil. hydr. mass. gr. vj ; 
pul. gum opii gr. iv in pil. No. 3. One to be taken three times to-day, 
and a dose of castor oil early to-morrow morning. Scrotum to be sup- 
ported with a suspensory bandage. 

25th. Oil had operated kindly; patient's general condition good; some 
serous infiltration of cellular tissue at upper part of scrotum. R. — Tinct. 
opii 5ss three times to-day; support scrotum as before. 

26th. Some suppuration about the points of suture. Warm water-dress- 
ing to be applied to part. Opium treatment continued. 

31st. Patient been doing well since last report. Apparatus removed by 
cutting sutures, and then carefully extracting the India-rubber plug with a 
forceps. The invaginated integument was found to be fixed ; its epidermis 
had been removed by the contact with the foreign body, and suppuration 
was abundant. Parts were now properly cleansed, and a thick compress 
retained over the inguinal canal by a spica bandage ; scrotum supported ; 
liberal diet allowed. 

February 15. Suppuration has ceased; there is some thickening of tis- 
sues about the canal ; opposing surfaces of invaginated integuments firmly 
united ; patient able to wear a truss quite comfortably. 

March "7. Patient has been induced to remain in hospital up to this time 
that his condition might be watched. To-day he was discharged well, and 
directed to wear a truss for at least two months. 



54 



Kinloch, Reducible Inguinal Hernia. 



[July 



Case II. T. M., a native of Charleston, set. 20, overseer on a rice plan- 
tation, entered hospital March 16, 1859. Has a small oblique inguinal 
hernia of long standing on the right side, and a large hydrocele on the left. 
He wished to be cured, if possible, of both affections. Health otherwise 
good ; bowels rather constipated. A blue pill and a dose of oil prepared 
him for operation. 

March 18. Patient chloroformed and operated on for his hydrocele with 
the metallic seton, and afterwards for the radical cure of his hernia. The 
procedure in the operation for hernia was a modification of the one I have 
just detailed, and is the one I now prefer, after having successfully practised 
it in several cases. A canular needle (Fig. I 1 ), two strips of India-rubber 

Fig. 1. Fig. 2. Fig. 3. 




Fig. 1. Canular needle. 

Fig. 2. First stage of operation ; the third and last -rc-ire about being passed by the needle. 
Fig. 3. Eepresents the arrangement of the rubber straps and the -wires after completion of the 
operation. 



(see Fig. Sab), and sufficient annealed iron-wire for sutures, are the instru- 
ments. They were thus used : After invagiuating the scrotal integument 
as usual, the canula was passed along the finger up to the internal ring, 
and the needle then thrust forward through all the tissues in front of the 
canal (see Fig. 2). The eye of the needle was next armed with a wire 
suture, and the needle retracted. The canula was again passed, and the 
needle thrust on as before, but its point was now made to appear externally 
a little lower and to the left of the first puncture ; thus, a second double 
wire suture was fixed in position, and finally a third one was passed by a 

1 This is a rough instrument, and was made extemporaneously from a female 
catheter. The canula of an ordinary trocar can be used for guiding the needle, 
if no better instrument is at hand. 



I860.] 



Kinloch, Reducible Inguinal Hernia, 



55 



puncture practised in the same way, but lower and to the right of the first 
one. Each double suture was now fixed near its middle to one of the strips 
of India-rubber, by closely twisting the wires about the strip at three dis- 
tinct points, as represented in Fig. 3 b. By traction upon the upper ends of 
the wires with one hand, while the strip of India-rubber was flexed and 
directed with the other (see Fig. 4), the strip was lodged in the canal, where 
it was to remain, forming an inverted semicircle. The upper extremities 
of the sutures that passed through the abdominal structures were now 
twisted over the other strip of India-rubber, which consequently represented 
externally a half circle, corresponding in length and direction with that 
formed by the strip within the canal (see Fig. 3 a). Lastly, the ends of the 
wires holding the external strip were cut off ; but the lower wires that 
passed through the canal were gathered into a bundle, wrapped around 
with a strip of adhesive plaster, and left to rest upon the scrotum (see 
Fig. 5). Patient was put to bed and ordered tinct. opii gtt. xxv; the same 



Fig. 4. Fig. 5. 




Fig. 4. Second stage of the operation ; the India-rubber strip fixed to the wires and about being 
pulled into its position in the canal. 

Fig. 5. Operation completed. The upper extremities of the wires have been twisted over the 
external piece of India rubber and cut off; the lower extremities of the wires have been fastened 
into a bundle and lie upon the scrotum. 

dose to be repeated at bedtime. The opium treatment was continued for 
several days. Patient suffered scarcely at all from the operation. 

2&h. The apparatus was removed with great ease, by cutting the upper 



56 Kinloch, Reducible Inguinal Hernia. [July 

wires in front and then carefully pulling upon the lower ends. Care was 
taken to draw first upon the suture attached to one of the extremities of 
the India-rubber strip, then upon the middle one, and finally upon the three 
together. By so proceeding all dragging upon the invaginated integument 
was avoided. The invaginated integument was found firmly adherent. 
The wires and India-rubber strip had developed free suppuration through- 
out the passage. Some superficial ulceration of the abdominal integument 
over the canal had also been produced by the pressure of the external strip 
of India-rubber. The parts were cleansed, and dressed with simple cerate 
and a compress and bandage ; the scrotum was supported by a suspensory. 
In a few days' time adhesion was perfect throughout all the invaginated 
portion of integument, and scarcely a trace of the operation remained. 
Patient remained in the hospital until the 21st of April, in consequence of 
an attack of pneumonia, contracted after his recovery from the operation 
for hernia. There was no disposition to a recurrence of the hernia, and he 
was discharged with directions to wear a truss for at least two months. 

Remarks. — I am not reporting the above cases with the view of advo- 
cating operations for the radical cure of reducible hernia. Although I 
believe that hernia has been cured by many of the procedures that are now 
employed, I think that all of these are uncertain, and practised with some 
risk. I consent to operate only on select cases, and when the patient 
specially desires it. I claim no particular originality or superiority in 
regard to the methods that I have detailed above ; but I believe they 
possess the merit of simplicity, and will succeed as well as the operations 
practised with complicated instruments. Within a few years there has 
been a general revival of the attempts to cure reducible hernia, occasioned 
mainly, perhaps, by the introduction of the instruments of Wiitzer and 
Rothmund, with their boasted claims to success. In the face of the 
reported success, I cannot forget that the spermatic cord has to pass 
through the inguinal canal, and that art can never more than approximate 
that beautiful and perfect natural arrangement, whereby the canal is closed 
to everything but the cord, and yet this not even so strictured as to have 
its circulation interfered with. In numerous cases art may for a time seem 
to have rivalled nature ; but if watched for a few months its imperfections 
become apparent — the boasted cures turn out to be only failures. The 
operation of Wiitzer has proved more successful with its originator and 
with Rothmund than with any one else. In England it has been faithfully 
tried, and has failed again and again in the hands of good surgeons. 1 
Among the cases operated upon in this city with Wiitzer's instrument, I 
know of several failures that were at first regarded as cures by the opera- 

1 A late letter of Dr. Mott, of Mobile, in the New Orleans Medical Journal, con- 
firms this fact, which I recorded in this manuscript, written in May last. English 
surgeons are now giving a trial to Mr. Wood's operation. 



I860.] 



Prince, Extirpation of the Parotid Gland. 



tors. With the instruments of Wiitzer and Rothmund the operation is 
easily performed, and in this consists the great merit of the plan. The 
principle of the operation is the same as that of Gerdy' s. From the single 
puncture resorted to in the plan of Wfitzer, sufficient plastic inflammation 
can scarcely be developed to secure the permanent invagination of the 
integument ; and in regard to securing this by the pressure with the out- 
side piece of the instrument, the attempt is apt to be either futile or hazard- 
ous — futile, if from over-caution too little pressure is exercised ; hazardous, 
if the amount of pressure risked is enough to occasion sloughing. If the 
metallic suture be used when practising the method of Gerdy, I believe that 
the operation would prove quite as safe and efficient a one as that of Wtitzer. 
In my own operations, I thought it better to modify the procedure of Gerdy 
and make use of the plug, or the internal strip of India-rubber (this latter I 
now think preferable, because, without distending the canal, it keeps a circle 
of the fascia and the invaginated scrotal integument in contact with its 
walls, and, moreover, it is more easily extracted than the plug), in order 
to secure the invagination. Where the sutures alone are employed, 
they are apt to cut and allow the invaginated structures to yield ; and, 
moreover, the presence of a foreign body of some size in the canal saves 
the necessity of resorting to irritating applications, as recommended by 
Gerdy, to bring about adhesion of the opposing surfaces. Since operating 
on the cases detailed above, my attention has been called to procedures 
somewhat resembling those I employed. Dr. Hackenburg uses a silk liga- 
ture and a perforated ivory ball. Dr. Richardson, of the University of 
Louisiana, makes use of the silver wire suture (Gross' Surgery). Redfern 
Davis, Esq., reports in the Medical Times and Gazette, February 12, 
1859, cases of femoral and ventral hernia operated on for the radical cure, 
by maintaining invagination of the integument by means of silver wire and 
small vulcanized India-rubber buttons the size of a split pea. 



Art. IT. — Extirpation of the Parotid Gland. 
By Dayid Prince, M. D., Jacksonville, 111. (With two wood-cuts.) 

Martha Walker, a negro woman, aged sixty, has had a tumour in the 
left parotid region during forty years. At first she says it was small and 
movable ; but it is now very firm, lobulated, extending from the ear, which 
is pushed back to what is usually the position of the angle of the mouth. 
The mouth is drawn towards the sound side from a paralysis of the mus- 
cles, probably from pressure and tension of the diseased growth upon the 
portio dura nerve. The patient has for a long time suffered great pain in 
and around the tumour, and has had ague during the autumn, and looks 
in a miserable condition. 



53 



Prince, Extirpation of the Parotid Gland. 



[July 



After several days recruiting, during which she was purged and given 
whiskey and quinine by day, with morphia by night, the extirpation was 
effected December 16, 1859. 

Before the operation the patient took an ounce of whiskey and a quarter 
of a grain of morphia. Then she was stupefied with a sufficient quantity 
of ether aud chloroform, three parts of one to one of the other by bulk. 
As soon after operation as she was sufficiently aroused she took half an 
ounce of whiskey and half a grain of morphia. 

Operation. — Present Drs. G-addis, Edgar, Knight, Jones, Long, of Jack- 
sonville, and Dr. Jayne, of Springfield, and some medical students. 

The patient lying upon her back with the head turned partly to the sound 
side, a zigzag incision was made from above and behind downwards and 
forwards, so as to leave several square inches of skin upon the tumour. 
Museau's forceps having been implanted into the tumour and given to 
an assistant with directions to lift upon the forceps, the tumour was 
rapidly raised from its attachment to the sterno-cleido-mastoid muscle 
partly by cutting and partly by tearing with the fingers. Anything looking 
suspicious of hemorrhage was tied, or was cut off on the distal side of the 
ligature, and the dissection carried further. The external carotid artery 
came into view, and was tied above the origin of the facial artery. The 
facial artery was torn across and did not require a ligature. All fears of 
bleeding now being at rest, the parotid region was very soon cleared out. 
In order to remove every vestige of the disease the zygomatic arch was 
chiselled away, the temporal fascia and a portion of the temporal muscle, 
and the whole of the masseter muscle, were dissected away. The posterior 
portion of the external surface of the buccinator muscle was entirely cleared 
off. After this the muscular bed of the parotid gland was carefully exa- 
mined and cleaned off, cutting away the temporary ligatures which had 
been applied as a precaution ; the only ligature remaining being that upon 
the external carotid artery. In this clearing out process, the submaxillary 
gland was found to have a suspicious appearance, and nearly all of it was 
extirpated. 

The ligaments of the temporo-maxillary articulation, the meatus audi- 
torius externus, the mastoid process, and sterno-mastoid muscle, the styloid 
process and styloglossus muscle, and the muscular wall of the pharynx, the 
digastric muscle and the hyoicl bone were brought into view. The last 
artery which bled was the internal maxillary, just as it dips behind the 
ramus of the inferior maxilla. This blood of course escaped from a retro- 
grade flow. 

The amount of blood lost was not great, and the operation was attended 
with fewer difficulties than had been anticipated. The serrations of the 
flap fitted nicely into each other. A few silver sutures, a few strips of 
adhesive plaster, some patent lint spread with simple cerate, a light com- 
press, and a retaining bandage comprised the dressing. 



I860.] 



Prince, Extirpation of the Parotid Gland. 



50 



Appearance of the tumour after extirpation. — The tumour was found 
to be distinctly divisible into three portions, two of which were imperfectly 
encysted, and the third not at all encysted. 

The anterior half of the main tumour presented exactly the appearance 
of a scirrhus of the mammary gland in the stage of softening. The centres 
of the softened portions were semifluid, while, from these centres outwards, 
the material became gradually consistent, and then hard as leather. 

The posterior half of the tumour had the appearance of original enee- 
phaloid growth, with fibrous bands traversing it in every direction, as if 
these might be the original divisions between the glandular cells of the 
parotid. This material occupied all the region of the parotid, and was 
separated from the anterior scirrhus portion by a distinct fascia, which 
appeared to be the original fibro-membranous investment of the parotid. 
This parotid portion of the tumour maintained a vivid redness upon its 
surface after keeping in alcohol, although its interior appeared at the same 
time (the time of writing this article), white on cutting into it. The ante- 
rior portion exhibited a dirty gray colour, both upon its surface and in its 
interior. 

The third portion of the tumour was outside of the fascial investments 
of the other two, and extended up on to the temporal region, involving 
the temporal fascia. The appearance of this was that of crude scirrhus 
deposit in and among the natural textures, without any distinct boundary 
to make it practicable to distinguish with certainty where the diseased tex- 
tures ended and the healthy began. It was in the removal of their third 
portion that the zygomatic arch, temporal fascia, a portion of the temporal 
muscle, and the masseter muscle were cut away. 

The appearance of the tumour corresponds very well with the history of 
the case. There was first a movable tumour over the parotid, which was 
at first of very slow growth. Afterwards the parotid itself became the seat 
of cancerous disease, and the growth of this was more rapid. Lastly, the 
deposit of cancerous material began to be deposited above the tumour and 
interior to it. 

Subsequent history. — At bedtime the patient was able to swallow pretty 
well ; took half a grain of morphia. 

1*1 th. Second day, morning. Comfortable; has slept a good deal, and 
has drunk a good deal of water ; pulse 100. 

8 P. M. Pulse 120, and pretty full ; some drip from the wound. 

Bled from the arm fvj, and the pulse became soft. She is to take every 
two hours twenty drops of sweet spirits of nitre, and every four hours four 
drops of Norwood's tinct. verat. vir., and at bedtime half a grain of mor- 
phia, if necessary. 

ISth. Third day. Slept well, and was comfortable without taking the 
morphia. Tinct. verat. vir. kept up ; pulse 102. Took some gruel, and 
drank freely of water during the day. She was in perspiration during the 
latter part of the day ; urinated freely. Some drip from the wound. 



60 



Prince, Extirpation of the Parotid Gland. 



[July 



l$th. Fourth clay. Pulse 80. The veratrum viride is discontinued, after 
having been taken in four drop doses every four hours for thirty-six hours 
— altogether thirty-six drops. Some drip from the wound. She gets up 
and walks across the floor. 

20th. Fifth day. Pulse 80. Comfortable. Takes more nourishment. 
She takes a little whiskey and water, and one-third of a grain of morphia 
whenever there is pain or uneasiness. At night, pulse 100 ; whiskey dis- 
continued ; flaps swollen. 

21st. Sixth day. Vomited. Took infusion of senna and sulphate of 
magnesia, with free catharsis, and relief of uncomfortable symptoms. 

26th. Tenth day. Pulse varies from tO to 100. Extensive sloughing 
of the flaps ; wound granulating well ; the periosteum upon the inferior 
maxilla separated from the bone ; applied slippery elm poultice to the 
wound. She takes one-third of a grain of sulphate of morphia often 
enough to feel pretty comfortable ; some whiskey several times a day, and 
every night and morning five grains of sulphate of quinia. 

28th. Twelfth day. Pulse 90. She has had a good appetite, which is 
now diminished ; wound suppurating very freely. Same treatment. 

30th. Fourteenth day. Pulse 90 ; more appetite ; sloughs have sepa- 
rated, and the wound is clean, and is granulating finely; simple cerate 
substituted for the slippery elm. Quinine diminished to two and a half 
grains twice a day; other treatment the same. 

January 6, 1860. Twenty-first day. Wound diminished one-half. She 
takes two grains of quinia twice a day, and a tablespoonful of whiskey 
three times a day. She also takes freely of rich food. 

Sth. Twenty-third day. Nausea ; a brisk purge cures this and sharpens 
the appetite. 

The exfoliation upon the inferior maxilla is extremely thin, and is sepa- 
rated particle by particle, giving place to healthy granulation upon the 
bony surface. 

From this time she went on very well. It was necessary to keep up the 
stimulating and anodyne treatment until the wound was entirely cicatrized. 



The accompanying figures represent her appearance — Fig. 1, on the day 
before the operation, and the other, Fig. 2, on the first of March. 



Fig. 1. 



Fig. 2. 




I860.] 



Prince, Extirpation of the Parotid Gland. 



61 



Remarks. — Notwithstanding the frequency with which reports of extir- 
pation of the parotid gland occur in surgical literature — Yelpeau claiming 
to have removed it twenty times — there is still a doubt in many minds 
whether it ever has been or can be done. In Erichsen's excellent work on 
surgery occurs this doubting passage: " Excision of the parotid itself is 
occasionally spoken of, but is very rarely if ever done. I believe that in 
most, if not all, the cases in which it is stated that complete removal of 
this gland has been accomplished, tumours overlying and compressing it 
have been mistaken for it. It is evident that a diseased parotid could not 
be removed without the division of the external carotid and the portio 
dura." 1 Very true ; but the external carotid and the, portio dura are not 
essential to life, though the portio dura is very essential to symmetrical 
expression. 

Yelpeau thinks, "The question whether the parotid in its totality may 
be extirpated has been incorrectly stated. The salivary glands, including 
with them the parotid, scarcely ever degenerate. The tumours that have 
been removed under their name almost all belong to other tissues and to 
other organs. Even in the substance of the parotid itself there are a great 
number of lymphatic ganglions. These ganglions, when they swell, become 
fungous, tuberculous, and cancerous, and are transformed into bosselated ' 
tumours, which spread out, flatten, and disorganize the glandular tissue, 
and lead to misconception of the real character of the parts extirpated." 2 

Chelius makes no such distinction, but says : "The parotid gland is sub- 
ject to a variety of degenerations of its tissue, by which its size is increased, 
and a larger or smaller swelling is produced. It may be the seat of indu- 
ration, of a sarcomatous degeneration, of scirrhus and cancer, and of medul- 
lary fungus. * * * 

"The removal of the parotid gland belongs to the most difficult and 
dangerous operations, and is by many considered totally unpermissible. 
* * * Experience has repeatedly proved the possibility of extirpating the 
parotid." 3 

Samuel Cooper, in his "Surgical Dictionary," thinks the parotid was 
repeatedly extirpated in the last century. Dr. Reese, in a note to Cooper's 
Surgical Dictionary, gives Dr. Samuel White, of Hudson, K Y., the credit 
of having first performed this operation in the present century, having suc- 
cessfully done it in 1808.* 

Dr. Brainard, of Chicago, who has reported a case of extirpation of the 

1 The Science and Art of Surgery, by John Erichsen, Blanchard & Lea's edition, 
1859, p. 741. 

2 Velpeau's Operative Surgery, Mott's edition, N. Y., 1847, vol. iii. p. 446. 

3 Chelius' Surgery, by South, Lea & Blanchard's edition, 1847, vol. iii. pp. 522, 
523, 524. 

4 Cooper's Surgical Dictionary, by Reese, Harper's edition, 1836, vol. ii. p. 259. 



62 Prince, Extirpation of the Parotid Gland. [July 



carotid in this journal, for October, 1853, and two subsequent cases in the 
Chicago Medical Journal, for December, 1859, thinks the operation is 
easier of execution when the gland is enlarged in disease than when in its 
healthy state, on account of a lifting up of its deeper substance, and he 
quotes M'Clellan as being of the same opinion. As Dr. M'Clellan per- 
formed this operation eleven times, he ought to have become familiar with 
its difficulties and facilities. 

The most important point in this operation is to choose such an order 
in the dissection as will enable the surgeon to obtain an early command of 
the bleeding by ligature or rupture of the external carotid and its branches. 
To this end the lower (proximal) portion of the tumour must be lifted out 
of its bed first, and the upper (distal) portions of the tumour dissected or 
torn away afterwards. 

Yelpeau, notwithstanding his twenty operations, seems unmindful of this 
point, for he advises, "To commence at the superior part, and then go to 
its posterior border, in order not to fall upon the carotid at the begin- 
ning." 1 

Malgaigne gives exactly the same advice : "The diseased mass is detached, 
commencing at its upper portion, and then its posterior border, * * * you 
thus avoid wounding the carotid in the outset of the operation." 2 

Liston's advice is much better : " The dissection should be carried deeply 
to the lower boundary of the disease, where the vessels are known to enter ; 
these will at once be divided and compressed ; or they may be tied, either 
when very large, or when the fingers of the assistant are in the way of the 
further and perhaps more delicate dissection. Thus, the operation is pur- 
sued safely and satisfactorily, and it will be found always much better to 
meet the danger at once than to be obliged to tie one vessel after another, 
perhaps securing the various branches over and over again, instead of the 
trunk ; much less blood will be lost, the time occupied in the operation 
will be abridged, and the pain and suffering very much diminished ; in point 
of fact more may thus be effected, and with equal safety, in five minutes 
than can be done in fifty, when the proceeding is otherwise conducted." 3 

1 Velpeau, by Mott, vol. iii. p. 448. 

2 Malgaigne's Operative Surgery, translated by Brittan, Blanchard & Lea's edi- 
tion, 1851, p. 347. 

3 Liston's Practical Surgery, by Norris, Philadelphia, 1842, p. 327. 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



G3 



Art. Y. — Animal Chemistry, audits Relations to Therapeutics. 
By J. L. Teed, M. D., of Mendota, 111. 

Among the many problems presented to the consideration of the physi- 
cian, perhaps none demand so much of his attention as those relating to 
Nutrition, while none are more intricate or more difficult of solution. From 
the first introduction of the food to its deposition as tissue, or rejection as 
waste, a series of changes are continuously in progress full of the deepest 
interest, and on the correct performance of which the comfort, and even the 
very existence of the individual depend. The growth of infancy to child- 
hood, and of this to mature years, with the future development of a healthy 
or diseased offspring, the very foundations of individual prosperity and of 
national greatness, have the due performance of these series of functions for 
their support and basis; while the daily health of every individual is, in by 
far the larger number of persons, good or bad, as these acts are well or ill- 
performed. The prevention of disease, also, relies chiefly on these acts as 
its sheet anchor, and in their treatment they present an importance of the 
first magnitude. If they be, therefore, so closely interwoven with every 
thread of our existence, of how much importance is it that the most correct 
views be entertained with regard to them, and that we should be able to 
follow them through their numerous ramifications. In continuing, there- 
fore, our subject of "animal chemistry and its relations to therapeutics" we 
shall commence with Nutrition. 

In its most extended sense this embraces — 1. Food and drink. 2. The 
formation of the nutritive fluid, including the complete digestive act. 3. 
The nutritive act, properly so called. 4. The removal of effete matter 
thereby occasioned. 

A very extensive work on the subject of food has been lately published 
at Giessen, by Dr. Jac. Moleschott, of Zurich. The first part, or the text, 
contains 5^0 pages ; the second consists of 355 tables, covering 254. pages. 
The tables are chiefly analytical, some being comparative of various articles 
of food, showing their composition and relative value in several constituents. 
Such a compilation, if correct, cannot fail of being valuable, condensing a 
fund of information, which it would require years to collect. 

The body of the work is divided into ten parts — 1. Elementary Princi- 
ples. 2. Their course in the Human Body. 3. The Necessity of Food. 
4. The Kind and Quality of Elementary Principles required to meet the 
wants of the System. 5. Animal Meats. 6. Vegetable Meats. T. Spices, 
Condiments, &c. 8. Drinks. 9. Physiological Properties of Meats, Spices, 
and Drinks. 10. On the Choice of Food. 

This work may be rather considered as an elementary treatise ; after a 
very careful perusal of the first six and ninth chapters, and a more cursory 
one of the last, there appeared nothing particularly worthy of notice, except 



64 Teed, Animal Chemistry, and Therapeutics. [July 

that the author had apparently examined all the travels in all parts of the 
world with the view of ascertaining on what the inhabitants of different 
countries subsisted. The analytical department of the subject is entirely 
omitted. The general chemistry and the physiology are sadly defective ; it 
may be said to be of the most superficial character. Had the author en- 
tered into the details of the most reliable methods used in determining the 
presence and the amount of the various proximate alimentary principles in 
the different articles of food, and the examinations of these in the various 
stages of assimilation, and so forth, omitted much of his superficial matter, 
and thus given the space devoted to the food of savages to the minute 
examination of the diet of civilized nations, his work would have had a 
real and important value ; as it is, the tables in the end are the only parts 
of much value. The work, however, will answer as a primary introduction 
to the study of dietetics ; or, as a species of light reading, some amusement 
may be derived from learning the dietetics of distant lands. In his phy- 
siology the author follows the school of Mulder, whose protein and protein 
oxide theory he altogether accepts. 

There is a great natural division of animals into carnivora and herbivora, 
a subdivision of the latter being graminivora; besides which are omnivora, 
including man. We have, therefore, in "comparative nutrition," that of 
i all these classes of animals, all and each of which contains a rich field for 
investigation. Bischoff and Yoit have paid particular attention to the 
nutrition in carnivora, and have lately published a most interesting treatise 
on it, to which we shall hereafter refer at some length. 

The food of man may be briefly enumerated as containing muscular, 
adipose, and gelatinous tissues, the cereal grains, and various vegetables, 
milk, salines, and water. The composition of the cereals is very similar to 
that of muscular tissue, while vegetable albumen, fibrin, and casein, corres- 
pond to those of the animal kingdom ; only the inhabitants of the Arctic 
regions and of the Pampas of South America adopt a diet exclusively 
animal, the former using immense quantities of animal fat to supply the 
want of hydrogen and carbon, while the latter almost live on horseback, 
constantly using immense exertion, and only continue this mode of living 
for certain periods. The vegetable kingdom, however, furnishes the largest 
amount of human food; although flesh meat of one or other kind may be 
said to be the most important, no dietary being fully adequate to support 
human life without it, or its analogue equally derived from the animal 
kingdom. 

The parts to be nourished, that is, the tissues, require special considera- 
tion, both with regard to their composition and their morphological 
arrangement. The tissues which have been the most fully investigated 
are, perhaps, bone, cartilage, and muscle. Other tissues have received a 
large share of attention, but these will suffice as giving a good general 
idea of the subject. 



I860.] Teed, Animal Chemistry, and Therapeutics. 



65 



The muscular tissue is composed of the muscular fibre or tissue proper, 
of connective tissue which binds the fibrils into fibres and connects those of 
each muscle into a unit, of vascular and nervous continuations, and at either 
extremity it terminates in tendinous expansions connecting it to the parts 
intended to be moved by it. 

The ultimate structure of the muscular fibril is still an undecided ques- 
tion : but, whatever may be the shape of the ultimate element, all authors 
are agreed that it consists of a cell, and that the fibril is formed by the 
superposition of these cells in the longitudinal direction. Now, "if in the 
living animal a muscle be separated from the surrounding tissues and left 
in connection with the rest of the body, only by the vascular and nervous 
trunks distributed to it, and then by electrical irritation be excited to 
repeated and long-continued contractions, there will ooze from its upper 
surface a yellowish glutinous fluid which will drop so constantly that it 
may be collected in considerable quantity in a vessel placed to receive it." 
(Wundt, quoted in Arch, fur Phys. Eeilk., 1859, p. 146.) This fluid is 
supposed to be contained in the "plasmatic vascular system" of J. G-. Ses- 
sing, which, as offshoots from the capillaries, convey only liquor sanguinis 
as their ordinary contents. Whether as Bowman describes, the muscular 
cells be discoid, or quadrilateral as according to Queckett, these vessels must 
pass in the connective tissue between the fibrils ; and by their means every 
single cell throughout the entire muscle may be, and doubtless is, brought 
into immediate contact with the "living stream," from which it thus derives 
its nutriment direct, and not by transmission through other cells, as would 
be the case if the capillaries alone were the smallest nutrient vessels. 

The osseous has as intimate relations to the blood stream as the musuclar 
tissue, for it "is certain that the organization of bone is such that, notwith- 
standing the rigidity of their structure, they are in the most general and 
the most intimate relation with the nutritive plasma of the blood. In 
every situation when the osseous tissue is in connection with vessels, as on 
the external surface, in the walls of the medullary cavities and cancelli, and 
those of the Haversian canals, millions of closely crowded minute openings 
exist. These convey the blood plasma by means of the canaliculi into the 
lacunae lying nearest to the surfaces mentioned, from which it is then con- 
ducted by wider canaliculi to the more distant lacunae as far as the outer- 
most layers of the Haversian lamellae, and those lacunae of the great lamellar 
system, which are most remote from the vessels. When the enormous 
number of the canaliculi and their multifarious anastomoses are considered, 
it must be allowed that no tissue in the human body is better prodded for 
in respect of the distribution of the blood plasma, whilst in scarcely any 
.other is the direct conveyance of the fluid to the most minute particles 
more immediately necessary than in it. There can be no doubt that the 
fluids which this plasmatic vascular system (of Lessing) of the bones obtains 
No. LXXIX.— July 1860. 5 



66 



Teed, Animal Chemistry, and Therapeutics. [July 



from the bloodvessels are most indispensably requisite for the maintenance 
of the bone." (Kolliker, Micros. Anat., Tr. by Busk & Huxley, p. 338, 
Am. ed.) 

The same mode of structure is then found in both these tissues, and the 
same method of nutrition, viz., of direct and immediate contact between the 
parts to be nourished and the nutritive fluid 

By digesting bone in very dilute nitric or hydrochloric acid we obtain 
the cartilaginous portion of the bone separately by itself, retaining all the 
shape of the bone, while by calcination the earthy part of the bone is pre- 
served alone, equally preserving the original form. It is certain, therefore, 
that the two elementary constituents must be most intimately combined, 
perhaps not in chemical combination, but certainly not in merely mechanical 
mixture. The exceeding vascularity of osseous tissue shows us that both 
these elements, the collagenous and the earthy, require and receive a most 
minute juxtaposition with the nutritive fluid, while the energetic molecular 
change, which is continually occurring in them, teaches us that after osseous 
deposits have taken place they are not considered as outgrowths, to be pro- 
vided for by the chances of circumstances, but that as it was necessary that 
the primary deposit of the earthy in the collagenous tissue should take place 
from the plasma, not by an act of crystallization, but by an act of vitality; 
not by a precipitation of effete matter, but by an act of secretion ; and as 
this plasma must of necessity be brought to the secreting structure by a 
vascular channel, so this " molecular change" teaches us that these channels 
of vascular supply are as equally needed for the purposes of nutrition as 
. primarily for those of formation. The diseased conditions of bone point 
also to the same end, of which the increased density and removal of colla- 
genous element in old age, the defective secretion of the earthy element in 
rickets, the fatty degeneration in osteo-malacia, may be cited as examples. 

To obtain a complete conception of the nutritive fluid it is necessary to 
examine not only the processes through which every article of diet has to 
pass, before it or any part of it becomes converted into blood, but also to 
consider the modifications produced by every separate article of diet as well 
as by the variations in which these are found in different dietaries. Such a 
detail being at present a simple impossibility, we shall notice only some of 
the more prominent features of the subject, and we propose to trace the 
processes to which the food is subjected in order that from it the nutritive 
fluid may receive its replenishment ; and we shall consider each process 
separately with its peculiar effects on each element of food, premising that 
our object is to bring out leading principles, reserving an argumentative 
consideration of certain points for a future opportunity. 

The first process is that of mastication, which needs only to be mentioned 
as a mechanical act of subdivision, but is of too much importance to be 
omitted, although too frequently neglected in practice, becoming thereby 
a "fons et origo niali;" a certain amount of atmospheric air, therefore of 



I860.] Teed, Animal Chemistry, and Therapeutics. 6T 

oxygen, becomes thereby mixed with the food. The next is the process of 
insalivation, or the commixture of the food with the mixed saliva. In the 
Lecons de Physiologie, of M. Bernard, toI. ii., 1856, is a full detail of 
the salivary secretion to which we would refer the reader, giving here only 
a condensed view of the most important points. 

The saliva secreted by the different glands differs widely in its characters 
and quantity; that of the parotid is the most watery and abundant, and is 
secreted principally during the act of mastication ; that of the submaxillary 
is more scanty, but more viscous, and is more plentifully secreted during 
excitation of the nerves of taste ; that of the sublingual and buccal glands 
being the most scanty, but excessively glutinous, facilitating the act of 
deglutition ; the viscous element is called ptyalin. The reaction of the 
saliva is very alkaline. The secretion is not constantly the same in quan- 
tity, but is intermittent, depending on the presence or absence of its exciting 
causes. It is increased by dry and pungent foods, lessened in amount by 
moist and sapid food. 

On albuminoid and fatty matters the saliva exerts no influence ; but it 
has been long since observed that it possesses the property of converting 
starch into sugar ; this has been attributed to a certain special substance 
contained in it, which has received the name of salivary diastase ; this body 
is not, however, peculiar to saliva, but seems to be a resultant of the spon- 
taneous decomposition of all nitrogenous matters, whether vegetable or 
animal, under the influence of oxygen ; and it may originate in the saliva 
from the decomposition of some of the salivary constituents, such as epithe- 
lial cells, &c, in the oral cavity itself — a circumstance which is rendered 
more probable by the fact that morbid saliva is more energetic than healthy, 
as in mercurial salivation, and in inflammation of the mouth : and the 
greater activity of human saliva over that of all other animals may be owing 
to the continual access of air to the oral cavity. 

It must be remembered, however, that complete putrefaction destroys 
this property. The presence of acids also arrests decomposition and pre- 
vents the further action of the saliva on the starch, not, however, hindering 
the operation of such "diastase" as may be already formed if used imme- 
diately; but if kept a day or two acidulated saliva no longer acts upon 
starch. The sole action of insalivation then on alimentary matters is to 
convert starch into dextrine and glucose or grape sugar. As soon as the 
alimentary bolus enters the stomach it becomes mixed with the gastric juice, 
a fluid strongly acid from the presence of lactic, or according to some of 
hydrochloric aoid, and containing the animal principle, pepsine. The quan- 
tity of gastric juice secreted is very differently stated by different authors ; 
although a very important matter, we can hardly deduce bases for thera- 
peutic action from our present knowledge ; we may say, however, that a 
certain degree of dilution is necessary for the due performance of the diges- 



68 Teed, Animal Chemistry, and Therapeutics. [July 

tive act, and we sometimes find advantage from tepid diluents shortly after 
eating, in some cases of difficult digestion. 

On fatty matters the gastric juice exerts no influence ; the fat is simply 
liquefied and floats free in the mixture known as chyme. 

On starch and sugar the gastric juice exerts no influence, but the action 
of the saliva on the starch becomes hindered as soon as the saliva becomes 
acidulated by the gastric juice to the extent above mentioned. On albu- 
minous and gelatinous substances the gastric juice exerts a powerful influ- 
ence, dissolving them, and also modifying their properties, so that they, 
although previously intransmissible through an animal membrane, now 
permeate it readily; they become more easily soluble, are less easily coagu- 
lable, gelatin ceases to gelatinize, and they lose the property of forming 
insoluble combinations with most metallic salts ; but they are so precipitated 
by tannic acid, chloride of mercury, and acetate of lead when mixed with 
ammonia. 

In the stomach a large portion of the received matter is absorbed, espe- 
cially of the fluids. Water is rapidly taken up, as also those solutions 
which will permeate a membrane having the blood serum on the opposite 
side, such as spirituous, weak saline, saccharine, and albuminous solutions ; 
it is, however, only a limited quantity of the solid portion of the food that 
is absorbed in this organ ; by far the larger quantity becomes mixed up 
into that homogeneous mass, the chyme, which is gradually transferred to 
the duodenum, to be still further modified by the pancreatic, biliary, and 
intestinal fluids. In addition to the gastric juice the stomach, like all other 
mucous surfaces, secretes ordinary mucus ; that this is not an indifferent 
substance to the digestive process is seen from the fact that if in large 
quantities, it acts very injuriously, preventing the operation of the gastric 
juice, perhaps also to a certain extent supplanting it, and causing fermenta- 
tions of various kinds, with the formation of abnormal products : in what- 
ever quantity it may be present it, with the saliva, nasal and pharyngeal 
mucus, and the gastric juice, contain more or less excrementitial matter, 
which is probably the reason of its becoming an exciter of fermentation, as 
was observed in the case of the saliva. 

A certain amount of atmospheric air, and therefore of oxygen, is con- 
veyed into the stomach, and occasionally of carbonic acid also. G-ases are 
as readily absorbed by the gastric as by any other mucous membrane, the 
walls of the vessels being as equally exposed ; under the influence of heat 
and moisture, and during the various molecular alterations which here 
occur, the effects of oxygen are more energetically manifested, especially 
where the nerve force of the organ is diminished ; a point worthy of atten- 
tion in cases of dyspepsia, attended with production of excessive acidity. 
The small excess of the nitrogen in expired air over that of the inspired 
air may be derived from this source ; there being no evidence that atmo- 



I860.] Teed, Animal Chemistry, and Therapeutics. 



69 



spheric nitrogen ever enters into any combination whatever in the human 
body. 

The especial action of the pancreatic juice, which is a highly albuminous, 
alkaline secretion, is to convert starch into sugar, and to emulsify fats, so 
that they are easily absorbed. Bernard (op. cit.) gives a very full account 
of the pancreatic secretion, and its influence in digestion ; according to him, 
it serves also to redissolve albuminous matters, after they have been pre- 
cipitated by the bile, from their state of solution in the gastric juice. The 
chief exception to his account of the digestion of fat by the pancreatic juice 
is its formation into glycerine and fatty acids ; such an acidification of oil 
or fat as takes place outside the body would be quite abnormal within the 
body: it requires a longer period for its accomplishment in a water-bath 
than could be allotted to it in the intestinal tube ; while such a formation 
of acid as we shall have occasion to notice more at length presently is a 
general accompaniment of difficulties in the digestive process. The great 
probability is, that fat is absorbed as neutral fat, emulsified by means of the 
pancreatic secretion, or chiefly so, that is, divided into small particles, each 
of which is surrounded by an albuminous envelop. 

Poured into the duodenum at the same time with the pancreatic juice is 
the bile, another alkaline secretion, and one of the most important of all 
the fluids engaged in the digestive process. The action of the bile, like 
that of all the other fluids of the digestive canal, is still a subject of con- 
siderable discussion ; it may assist somewhat in emulsifying fat ; it, in all 
probability, has decided antiseptic properties ; it may precipitate albumin- 
ous matters from their state of solution. Its water serves largely as a 
means of transit of biliary matters from the blood, and of nutriment and 
of other soluble matters from the intestinal tube back again in the blood- 
stream. 

The various glands in the duodenum, jejunum, ilium, and caecum, still 
further supply a series of fluids for the solution of nutritive matter, its 
elaboration and absorption, and the venous radicles throughout the whole 
intestinal tube collecting the absorbed food, pour it by one common trunk 
into the liver. As, however, cases are on record where the vena porta, 
instead of traversing the liver, entered at once into the vena cava, without 
any disturbance to the ordinary functions of life having been sustained, 
such an occurrence would prove that the food did not require any further 
assimilation than what it obtained by means of the various intestinal pro- 
cesses, before being perfectly capable of being applied to the purposes of 
nutrition. In these cases the liver secreted the bile from the blood of the 
hepatic artery. 

As a summary, then, we may state that albuminous matter, whether 
vegetable or animal, is absorbed as albumen, gelatinous matter as gelatin, 
these being both modified, as before stated. Starch and saccharine matters 



10 Teed, Animal Chemistry, and Therapeutics. [July 

are absorbed as grape-sugar and dextrin, and fat principally as neutral fat, 
a small portion of fatty or other acids being formed. 

According to Moleschott, in his work above noticed, the digestion of 
amylaceous food proceeds thus : The starch is first converted into dextrin, 
C 12 H 10 10 ; this absorbs 2HO, and becomes grape-sugar, C 12 H 12 O l3 . This 
change may occur throughout the whole length of the intestinal tube, from 
mouth to rectum. The sugar then loses 2HO, and becomes hydrated lactic 
acid, C 12 H t0 O 10 -(-2HO, which occurs partly in the stomach, more so in the 
small intestines, but principally in the caecum. The hydrated lactic acid 
then becomes split up into hydrated butyric acid, C S H 7 8 4- 3HO,4H,4C0 2 , 
which occurs principally in the colon. This metamorphosis of the fat- 
formers (Fettbildner) into a series of acid formations, like Bernard's forma- 
tion of fatty acids noticed above, is open to some very serious objections, 
is quite contrary to deductions from pathological phenomena, and- is quite 
opposed to the teachings of therapeutics ; if followed out, it would certainly 
lead to a very injurious practice ; for if this were the mode of their normal 
digestion, attacks of indigestion would be most readily relieved by the use 
of means that would promote acidification; and in cases of weak digestion, 
these acids, taken directly, would save all the labour of their formation 
from these substances, thus a large amount of force would be saved, and 
digestion would be so much the more easy. 

In various pathological conditions, especially in states of hyperemia and 
irritation of the gastric mucous membrane, large quantities of mucus are 
thrown off, while in many of these cases the proper secretion of gastric 
juice is checked; this mucus very readily enters into or induces various 
decompositions known as fermentations, partly from want of a better name, 
and partly because these processes may be simulated by fermentative pro- 
cesses outside the body. Instead, under these circumstances, of the aliment- 
ary principles being dissolved and absorbed in the condition produced by the 
normal or healthy secretion of the part, acids of various kinds are produced; 
thus, albuminoid, saccharine, and fatty matters will give rise to lactic, acetic, 
butyric, and other acids, while other foreign bodies will necessarily be formed, 
containing the nitrogen, sulphur, and phosphorus of the albuminoid matter. 
These will be as largely absorbed as they are formed, and the consequences 
will be a disturbance of the ordinary alkaline reaction of the blood, lithic 
acid will be discharged extensively by the kidneys, either alone, but more 
generally in combination, other acids will be thrown off in the sweat, 
various fetid matters will pass off from both skin and lungs, and numerous 
morbid states induced, dependent on this state of acidity, and the relative 
weakness of this or that organ. The means of cure assist in the explana- 
tion of these phenomena. Alkalies, especially potash, which, forming the 
most soluble salts, is most readily discharged by the kidneys, alkaline earths, 
which, forming more insoluble compounds, pass off by the bowels, are the 
most successful remedies by which, with moderate evacuants, we rid the 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



71 



system of the amount already formed ; we then check the further develop- 
ment of such acids, in which the real cure consists. This is done in three 
ways : one, by directly developing nervous force, as by travelling or voy- 
aging, or much exercise in the open air, and preferably where the mind may 
at the same time be agreeably entertained ; a second, by directly supplying 
the deficient element, as by administering pepsin ; and the third, by mineral 
acids, tonics, and antiseptics, with or without sedatives and counter-irritants, 
the food being, at the same time, that most easily and extensively digested 
• by the parts of the intestinal tube least affected, so as to allow the weak 
part to rest as much as possible, that its irritation may subside, and its 
force be regained by cumulation. The more we can effect by dietetic man- 
agement and by hygiene, the more permanent will be the cure, and, with 
proper care, the less liable will the disease be to return ; this much, however, 
being self-evident, that the manner of life, or whatever cause, first inducing 
the disease, will be the one most likely to cause its return, and hence a 
frequent cause of failure in the treatment of dyspepsia, patients either will 
not or cannot give up or alter that mode of life under the influence of 
which the disturbance first originated. 

If such be the teachings of pathology and therapeutics, the hypothesis 
of acid formations as the regular mode of digestion of starch, sugar, and 
fat must necessarily fall to the ground. The subject is one of such vast 
importance in every-day practice, that the author hopes this seeming 
digression will be pardoned. 

Having thus considered the formation of the nutritive fluid as far as the 
introduction of true alimentary matter into it, the fact remains to be noticed 
that all animal and some vegetable foods contain those proceeds of retro- 
grade metamorphosis which are peculiar to the tissue ; thus, muscular flesh 
contains creatine and creatinine, and what other residuary products of the 
nutritive act may be contained in its retained plasma or blood, particularly 
when the animal has died without previous hemorrhage. ~Now, as these 
are found directly in the excretions as well as in the tissue, it would be 
contrary to all known principles to suppose that these effete elements, 
introduced in the food, should be first raised to the condition of albumen, 
and then retrograde to their original composition. No upbuilding in the 
scale of composition occurs in the animal economy ; all alimentary sub- 
stances introduced into it must be of the highest and most advanced forma- 
tion of which they are capable. Albumen, for instance, cannot be supplied 
by any substance or substances of a lower grade, from which it may be 
subsequently formed in the organism itself ; all that we observe is, that 
nature has furnished us with several modified forms of the same substance, 
which are all convertible into one form, which may therefore be considered 
as the standard or typical form, their elementary composition suffering no 
changes, or but one of molecular arrangement, as we express it. We find 
in the carbo-hydrates a similarly convertible family, to which are closely 



72 Teed, Animal Chemistry, and Therapeutics. [July 

allied the fats, and in the metamorphoses which occur in the processes of 
assimilation and nutrition the direction is the same ; thus albuminous mat- 
ters may give rise to carbo-hydrates and fats, or their derivatives. Carbo- 
hydrates may also give origin to fats, but fats cannot give origin to 
carbo-hydrates nor albuminates, nor carbo-hydrates to albuminous forma- 
tions. Many, therefore, of the solid parts of the food enter the blood 
stream, only to be rejected by some peculiar excretion. This is an import- 
ant principle in the treatment of disease, especially when, from any disorder 
of function, either of excretion or of formation, any of the principles of* 
retrograde metamorphosis are in undue excess in the blood ; in such cases 
all alimentary substances, which, besides being convertible into such prin- 
ciples in the direct line of retrograde metamorphosis, contain any of them 
as an already existing element, a consequence of that act of nutrition 
which maintained their own existence while living, should be -avoided. 
Thus, in some diseases — as fevers — we find a great excess of uric acid, in 
others of urea ; from the changes in whichever of the nitrogenous tissues 
these or either of them may be derived, a flesh diet, especially gelatinous, 
which increases their amount, even in a state of health, is prejudicial, while 
a vegetable diet, under which they decrease, is to be preferred. We find also 
that the products of fermentation which are contained in food, a conse- 
quence of vitality, as in the case of sprouted grain, render it unwholesome. 

In addition to the water, sugar, albumen, and fat, the blood contains 
also another important class of nutritive principles, the salines. Some of 
these are combined with the nitrogenous principles, and this so intimately, 
that it is almost, if not quite, impossible entirely to separate them ; but in 
the act of nutrition they become separated when the albuminous body suf- 
fers decomposition, and obey the general laws of excrementitious matter. 
Others of them form a portion of nearly every article of food and drink, 
so that sulphur, phosphorus, iron, lime, and magnesia are but seldom used 
as dietetic, though often as medicinal substances, common salt being the 
mineral especially added to our food as a separate ingredient. As all 
these are being continually received with the ingesta, and removed with the 
egesta, they are constant ingredients of the nutritive fluid. 

The residua of nutrition, in their transit from their place of formation 
to that of their excretion, form very important component parts of the 
blood stream, as also all those unassimilable or unnecessary substances 
which may have been absorbed during the process of digestion, but are 
again eliminated by the excreting organs. Among these may be named 
carbonic acid, urea, uric, phosphoric, sulphuric, hippuric, lactic, and oxalic 
acids, creatine, creatinine, biliary colouring matter, extractive, &c. 

In addition to the above-mentioned components of the blood stream, all 
of which are present in the fluid or dissolved condition, there are another 
series of bodies, which belong properly to the class of solid formations, 
viz., the blood-cells, red and colourless, or the mature and young; these 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



73 



derive their nourishment from the plasma, and give off the residua of their 
nutrition, and the results of their destruction, to be separated by the elimi- 
nating organs ; the same rule holding good to them as to all other parts 
of the system, viz., that those molecules which, under any form, have been 
used in the processes of life, are no longer capable, when they have once 
passed through their stage of vitality, of again entering into the formation 
of animal principles of the same or of a higher order, but are either imme- 
diately eliminated, or become so after passing through successive stages of 
downward or retrograde metamorphosis ; thus, the iron of those corpuscles 
which become destroyed or broken up is expelled, and does not enter into 
the formation of fresh corpuscles, and its place must be supplied from 
without, by fresh iron, i. e. fresh to that individual ; this, although derived 
from another individual possessed of life, during the digestive process has 
its capability continued of entering into the composition and sustaining the 
functions of the living body consuming it, until it in its turn shall have 
become effete ; while any that may have become effete is not assimilated, but 
is discharged; and the organ chiefly containing these residua — as the spleen 
(and sometimes also the liver) — forms an article of food of very indifferent 
quality, and frequently causes great intestinal disturbance. In the case of 
the liver other effete matters may be also concerned. An excessive destruc- 
tion, a diminished supply, or a faulty assimilation, will therefore have the 
same ultimate effects, and a condition of aneemia or of chlorosis will be the 
result. In some cases an increased supply remedies the mischief, in others 
the destruction must be checked, and again in others the powers of assimi- 
lation must be increased. It is generally conceded that a great destruction 
of blood-cells occurs in the spleen ; in cases of ague we often observe con- 
gestive enlargement of this organ followed rapidly by anaemia. A short 
course of iodide of potassium, especially if taken early, is generally followed 
by subsidence of the congestion, diminution of the size of the organ, and a 
stop to the anaemia. The modus operandi is not the point in question, 
but that there is primarily congestion, that this is accompanied by destruc- 
tion of the blood-cells; and this results in ansemia because the iron is 
discharged, and fresh red corpuscles are not formed in sufficient quantity 
to replenish the loss ; but when the congestion is removed, the destruction 
of blood-cells ceases, and the anaemia is soon replaced by the ruddiness of 
health. These are sequences which speak for themselves. Examples of 
the first case in chlorosis, and of the third in some of the complicated 
forms of phthisis, present themselves in every-day experience. 

With the blood-cells and the alkaline carbonates of the serum are inti- 
mately connected the conveyance of the oxygen and carbonic acid gases, 
which are constant elements of the blood. 

The nutritive portion of the blood may, therefore, be comprised under 
water, corpuscles, albumen, sugar, fat, oxygen, and salines. 

We have before seen that the tissues to be nourished consist of cells lying 



74 Teed, Animal Chemistry, and Therapeutics. [July 

closely applied to a series of plasmatic or nutritive vessels ; in these tissues 
two acts are required to form by their combination the full nutritive act ; 
the first consists in the exchange of a portion of the cell contents for a 
portion of the circulating plasma, and the second in the formation of the 
heat necessary to vitality by the direct oxidation of certain substances, either 
primarily brought into the tissues by the fluid itself, or else derived from 
the accomplishment of the first act. From the formation of the tissues, as 
before shown, there arises of necessity a great opportunity for the full action 
of the oxygen present from the retardation of the circulation, and this re- 
tardation is evident from the following calculation : The amount of blood 
which passes through the left ventricle in a given time is derived from the 
whole circulating apparatus in the same time ; therefore, as much as the 
area of the extreme vessels exceeds the area of the left ventricle, by so much 
is the current through the extreme vessels slower than that through the left 
ventricle ; if otherwise, the heart would be irregularly supplied, being some- 
times completely empty and sometimes gorged, a condition of things not 
long compatible with life. And further as the area of the plasmatic vessels 
is still greater than that of the capillaries, and, as they form in a certain 
manner, courses out of the direct circulation, the rate of the current suffers 
still further retardation in them. 

As the first act of nutrition consists of an interchange between the cells 
and the vessels, of portions of fluids holding certain matters in solution, it 
is of necessity that the molecular changes occur in the cell-fluid and cell- 
walls and not in the vessel-fluids. The parts to be nourished consist chiefly 
of C,IE,X,0; their elements being no longer used in upbuilding tissues, but 
entering on a course of descending transitions, are finally expelled the 
system; the matters given off by the cells undergo a "dedoublenient" or 
splitting into two portions or classes, of which one is rich in nitrogen, the 
other being poor in that element, or, according to Bischoff, being entirely 
destitute of it ; this latter, under the influence of oxygen, forming C0 2 and 
HO, and thus generating heat. Hence nitrogenous food is absolutely essen- 
tial to nutrition in proportion sufficient to cover this loss, while carbo- 
hydrates chiefly serve the purposes of animal heat. Where a due supply 
of nutriment is not afforded, the matters dissolved in the exosmosing fluids 
cannot be fully replaced from the vessel-fluids ; and this decrease continues 
pari passu in the cell-fluids and in the vessel-fluids, the latter always retain- 
ing the predominance as long as any nutrient matter remains capable of 
being assimilated ; and when an osmotic balance is reached the cells neither 
give off nor receive ; life is, therefore, extinguished, and, after death, they 
are found pale and shrunk, but they are not dissolved, nor is there any trace 
that a single cell has been removed, from a muscle for instance, it is only 
the cell contents that have disappeared, i. e. their nitrogenous matters held 
in solution, a larger portion of the water still remaining and the muscles 
are said to be watery. (Virchow's Arch., vol. xviii. p. 174.) 



I860.] Teed, Animal Chemistry, and Therapeutics. 15 

As soon, therefore, as osmose ceases, the maintenance of animal heat 
ceases, because after all the carbo-hydrates and fat have been consumed, 
nothing remains but this splitting of nitrogenous matters ; and as soon as 
this is suspended, although there may be still inspiration of oxygen and 
absorption of it into the circulating fluid, there is no material on which it 
can act, as its action is neither on the nutrient fluid nor on the tissues, but 
on the matter given off from the tissues, which matter is replaced from the 
nutrient fluid. When, therefore, osmose ceases, the matter ceases to be given 
off, the action of the oxygen ceases from want of matter on which to act, 
heat ceases to be developed, and with this is the cessation of life. 

It is obvious that as each of the tissues has a different composition, they 
must each require a different molecular deposit, and the series of rejected 
compounds will also differ; thus the compounds arising from the splitting 
up of the effete atoms of the cerebral tissue will differ from those of the 
muscular, these again from those of the osseous, and all of them from those 
of tendinous, ligamentous, cartilaginous, and parenchymatous structures, 
and in the proportion in which the vital activity in any one of these tissues 
exceeds that in any of the others, or the general activity of the whole, will 
those proximate principles be more abundant to which that particular tissue 
will give origin ? At present, however, it would be premature to connect 
the formation of any principle with the molecular alterations of any organ. 

It would also seem to follow as a legitimate conclusion from this, that, 
at least in some cases, a " dedoublement" may occur in the albuminous or 
nitrogenous element deposited at the time of its separation from the nutri- 
tive fluid in order to become a component of the tissues. Should this be 
actually the case, it must follow that there must be more than one nitrogen- 
ous product of tissue change ; this especially appears when we consider the 
different composition of the different tissues, such as cartilage, muscle, cere- 
bral, and glandular tissues, blood-corpuscles, &c. &c. We can hardly bring 
ourselves to conclude that all the effete nitrogenous matter in all these dif- 
ferent tissues, and that both in formative and retrograde metamorphosis, 
enters into one single formation, sometimes, that is in the same tissue, 
giving off an excess of C and H, and at other times absorbing these ele- 
ments to supply the deficiency. And as we also find that differently com- 
posed nitrogenous foods occasion corresponding differences in the nitrogenous 
excreta, it would seem logical to conclude that corresponding differences 
occur in the tissue-change of such tissues in the organism itself ; thus we 
find that gelatinous food occasions a larger excretion of urea than the use of 
any other ; it is, therefore, no strain of argument to conclude that the tissue 
change in the gelatinous tissues occasions a greater formation of urea than 
the tissue change in any other tissue ; and, if such be the case with regard to 
the gelatinous tissue, to what especial principle does tissue change in each 
of the other tissues give origin ? Shall we be also obliged to declare that 
creatine, creatinine, &c, are products of the decomposition of urea during 



16 Teed, Animal Chemistry, and Therapeutics. [July 

the analysis? We can detect them in the muscular juice, i. e. in the food, 
and again in the excretions. Is it too much to suppose that they enter 
the blood stream only to be rejected by the proper secretion ? and, if so, 
why does not the tissue change in the muscular tissue especially give origin 
to these principles ? There are many substances which are absorbed into 
the blood stream from their osmotic or other physical properties, but being 
foreign to the organism are carried out of it again as soon as possible ; 
such are excess of water, chloride of sodium, several salines of daily and 
common use; it is, therefore, only an extension of the same rule to apply 
it to those principles of retrograde metamorphosis which may be contained 
in any article of food. Again, the osseous tissue is the seat of a very active 
circulation, and, consequently, of as active nutritive changes. May not this 
tissue give extensive origin to formation of urea ? The nervous tissue is 
especially rich in phosphorized fats, and the residua of its nutrition will 
have an especial reference to its composition. A clear and full comprehen- 
sion of the elementary composition of each organ and tissue will give one 
link in the chain of its nutrition by showing what elements are especially 
required, while by knowing the proximate principles from which these ele- 
ments are obtained, and by getting the especial results, if any, of feeding 
animals for some length of time, on such or such a tissue or organ, we may 
arrive at more definite conclusions on the subject ; the examination of the 
blood-stream coming from such organ or tissue may yield only negative 
results, if the principle sought be present only in very small quantity. 

The carbon, hydrogen, and oxygen given off in the splitting up of nitro- 
genous bodies, and arising from the direct absorption of non -nitrogenous 
matters, are given off chiefly as carbonic acid and water, sulphur and phos- 
phorus as sulphuric and phosphoric acids, in combination with various 
bases. Amongst the nitrogenous formations that of ammonia, as an 
original formation, is a matter of much dispute, as a constituent of food it 
is but rarely absorbed, but as an element of excretion it is often met with ; 
as ammonio-phosphate of magnesia it forms a frequent deposit in the urine, 
and is often met with in feces. The relations, however, between ammonia 
and urea are such that it is easy to suppose the latter may give rise to the 
former within as well as without the body. According to Lehmann, ammo- 
nia is nearly absent from healthy human urine. According to Yoit, it is 
also absent from that of carnivora, urea being its sole nitrogenous compo- 
nent. In order to be enabled to transfer the teachings of comparative 
experiments to the human subject, it is necessary to observe them through 
all classes ; and in nutrition in herbivora we have a very remarkable phe- 
nomenon, viz., the formation of hippuric acid; this not being peculiar to 
them, however, being also found in human urine. It is found, also, as an 
especial production after the use of a substance which contains no nitrogen, 
viz., benzoic acid, C 14 H 6 4 ; and after the use of some fruits, such as apples, 
plums, &c, as this acid is not found in the urine of carnivora, and under 



I860.] Teed, Animal Chemistry, and Therapeutics. 77 

certain feeding is also absent from the urine of herbivora, and also from 
human urine, and as its contents of nitrogen is only one-half that of urea 
while its carbon is eighteen times as great, and its hydrogen three times as 
great, it would seem that its formation depended on the combination of the 
nitrogenous portion of the effete matter with that excess of carbon and 
hydrogen over and above what the oxygen present could convert into car- 
bonic acid and water, which junction taking place in the nascent state, or 
while the various elements are rearranging themselves, it becomes a primary 
formation in the metamorphosis of tissue; in the same way as that an 
excess of carbon alone, or a relative deficiency of oxygen, occasions the 
formation of oxalic acid. 

From the foregoing we may deduce the following law : that, as the food 
consists of carbon, hydrogen, oxygen, nitrogen, &c, in varying proportions, 
and as the various tissues contain the same elements, and also in varying 
proportions, it is of necessity — that as these elements are neither taken in nor 
thrown out in their elementary form (except oxygen, this, however, not 
being taken pure), but in various combinations as proximate principles, just 
in proportion to the differences in the food, and in the relative tissue-change 
in each of the tissues, will the proximate principles of the excretions vary, 
not only in the amount of each, but also in the very presence or absence of 
any one or more ; and, therefore, the law of the formation of either one is 
not so much a law of the individual or species as a result of the circum- 
stances in which the individual was then placed. 

Bischoff and Yoit have lately published a work on the Laws of Nutri- 
tion in Carnivora. They kept a dog for about* fifteen months, and in this 
work they have given the results of their experiments. In order to give a 
better idea of the detail we will condense the argument contained in the 
first part of the introduction. 

They first declare the whole of their superstructure to rest on the fact 
that all the nitrogen (except air) discharged from the body is a product of 
tissue change, and tissue change only; that the idea of oxidation of nitro- 
genous matter in the blood-stream is erroneous ; and that the result of all 
the tissue change of nitrogenous tissues is urea, and urea only; and B. 
complains that his former work on this subject has not received the amount 
of consideration which it deserved. From the molecular decompositions 
are derived the various forces, of which two are especially noticed at some 
length : the force of motion, i. e. the internal motions, such as solution, 
absorption, circulation, and respiration ; and the force of heat — these forces 
being correlated, and mutually convertible. 

The author then argues that the motor forces are generated by the 
decompositions of nitrogenous matter under the influence of oxygen, per- 
haps under the form of ozone ; while heat is given off by the decomposition 
of fat and the fat-formers. The amount of motor force generated is pro- 
portional to the mass of the organ, and its continuance to its replenishment 



18 Teed, Animal Chemistry, and Therapeutics. [July 

by food; while the decomposition of both nitrogenous and non-nitrogenous 
is owing to the effects of oxygen, and the results in both carbonic acid, 
water, and urea may be considered as oxides. He then states the question : 
"If such be the decomposing influence of oxygen, how is it that the albu- 
men of the blood is not consumed by it?" To this he replies that the 
combination of matter with nitrogen greatly reduces its oxidizability and 
combustibility, and that thereby, i. e. owing to its nitrogenous element, the 
albumen in the blood is protected ; then he asks : How is it then that the 
nitrogenous tissues are decomposed under the influence of oxygen ? The 
following view of tissue change contains the answer : — 

The organ, the muscle, the cell are the material expressions of those 
molecular forces, which preserve their molecules in these separate forms. 
Their existence has, as a constant element, a continual interworking with 
nutritive material, e. plasma, and atmospheric oxygen. This interwork- 
ing consists of a double attraction, which both plasma and oxygen exert 
on this or that organ, and is produced only by the simultaneous co-opera- 
tion of both ; we may comprehend it best under the idea of a pressure on 
the part of the plasma, and an attraction on the part of the oxygen, which 
produce a fresh molecular arrangement in the organ. Neither oxygen nor 
plasma are sufficient separately ; both are required to produce these effects. 

The decomposition being always the result of the co-operation of all 
three of these factors, it is always directly proportional to the mass of these 
factors, i. e. of the organ, the plasma, and the oxygen. 

It is increased when the bulk of the organ is large or increasing ; it will 
decrease when the bulk of the organ is small or decreasing ; being, however, 
within certain limits independent of the quantity of the plasma or of the 
oxygen. 

It will increase when the bulk of the plasma increases, even if the bulk of 
the organ should not increase, and the action of the oxygen should not 
increase, but decrease. 

It will decrease if the bulk of the plasma decreases ; but it will in this 
case even exceed the quantity proportional to the plasma, if the bulk of 
the organ and the quantity of the oxygen be large. 

It will also increase if the quantity of oxygen be increased, even although 
the quantity of the organ or of the plasma be not greater, but less ; it will 
decrease if the quantity of the oxygen be diminished directly or indirectly, 
that is, if a portion of the oxygen be otherwise combined. 

It is evident, therefore, that decomposition is always a complicated pro- 
duct of the operation of these three factors, and can only be understood by 
a careful examination of all three. 

The bulk of the organ will be dependent on the relation which its replen- 
ishment by the food, i. e. the plasma, bears to its decomposition ; it will 
increase or decrease, or remain stationary in bulk, just as the plasma brings 



I860.] Teed, Animal Chemistry, and Therapeutics. ?9 



more or less fresh material, and as the decomposition is more or less active, 
or the quantity of oxygen is increased or diminished, or otherwise absorbed. 

By these decompositions force is liberated, and as heat is provided for by 
the decomposition of non-nitrogenous material, so by that of the nitroge- 
nous portions motor force must be supplied; while this is without question 
required for the keeping up the before-mentioned internal motions. 

If we consider an animal without food, and in a state of rest externally, 
it is then living on its organs and blood constituents ; it presents an amount 
of decomposition, depending on the bulk of its decomposing organs, and 
the quantity of albumen and absorbed oxygen in its blood. The force 
which is thereby liberated is used for the uninterrupted maintenance of the 
internal motions, which are absolutely necessary to its existence ; and it is 
proportional to the bulk of nutritive material moving in this condition, 
which, according to the bulk of the organs, gives the proportion of the 
decomposition on which the amount of disposable force is dependent, most 
strikingly exhibiting the harmony between cause and effect. 

As the decomposition is the result of the mutual operation of the organ, 
plasma, and oxygen, and as by it the force is liberated which is necessary 
for the internal motions, this is proportional to the amount of plasma to 
be moved ; and this last is again, the influence of the organ and of the 
oxygen remaining the same, the measure of the decomposition. 

When we give an animal food the amount of the blood of the plasma is 
increased, therefore also the amount of the decomposition is greater, and 
consequently a greater amount of force liberated, on which the movement 
of the plasma is entirely dependent, the bulk of the organ being considered. 

But with this view of the case the animal would still be in a fasting con- 
dition, and the loss of its organs would not cease, because the newly taken 
food would only yield the force necessary to provide for its own movement. 

But herewith is connected at each introduction of food a diminished ope- 
ration of the oxygen on the decomposition in the organ. 

While the primary result of the decomposition of nitrogenous matters is 
the supply of force necessary to internal movements, there are subsequently 
formed products, having reference only to the development of heat. The 
greater the decomposition from increased supply of food, the greater the 
amount of these products of decomposition, and therefore the more oxygen 
will be absorbed by them. But the disposable quantity of oxygen in the 
blood is limited. The more therefore is used as above, the less remains for 
the primary decomposition, of which it also is a factor. The influence of 
the bulk of the food on the decomposition bears an inverse proportion to 
the operation of the oxygen on it. When the former is increased the latter 
is diminished, from the increased amount of decomposition products ; and 
when the former is diminished the latter is increased, because less is then 
absorbed by the fewer decomposition products. Both influences are not 



80 Teed, Animal Chemistry, and Therapeutics. [July 

developed in an equally strong degree, consequently they do not generally 
act equally strong on the decomposition ; but they are developed, and act 
only proportional to one another. In proportion as the supply of plasma 
increases, in the same proportion the operation of the oxygen is diminished. 
The general result being that with a stronger flowing plasma the relative 
decomposition of the organs is always less. So long, therefore, as supply 
and decomposition are not in equal proportion, the portion which the organ 
loses by its decomposition will gradually decrease with the increase of the 
supply, until an equilibrium is reached in which the supply entirely replaces 
the decomposition in the organ ; and if the former be still increased, then 
the possibility of deposition, and consequent increase of the organ is induced. 
But in order that this should continue, the supply must be still further 
increased. For as soon as the mass of the organ increases, the decomposi- 
tion is consequently increased, and the same amount of food yielding now 
no longer an excess, indeed not much longer an equivalent, but very soon 
a relative deficiency, a decrease of the organ again ensues. In this manner, 
by increasing the supply and consequent diminution of decomposition from 
absorption of oxygen, by increased decomposition products, an increase of 
the organ will ensue, until the operation of the oxygen is so much reduced, 
and the decomposition sinks so low, that the force necessary for the assimi- 
lation and movements of the food can be no longer supplied. The animal 
then ceases to eat ; but as the decomposition is continued, whilst the supply 
is diminished, the equilibrium is soon re-established, and sufficient force is 
soon generated for a fresh movement and assimilation of the food. 

The same effect which is produced thus indirectly by the increased amount 
of decomposition products is brought about directly by the entrance of 
oxidizable substances — as fat, sugar, and alcohol — into the blood ; which, 
by absorbing the oxygen, lessen the amount of the general decomposition. 
This will be always somewhat proportional to the supply of albuminous 
plasma. Is this very limited, as the result of an entire want of nitrogenous 
food, then the decomposition will be diminished in proportion to the quan- 
tity of fat and sugar consumed ; it will, however, from the circumstances 
mentioned above, always remain sufficiently great to supply the forces 
necessary to the maintenance of the internal movements. This internal 
force is but little influenced by the taking of fat or sugar ; for, as these 
matters pass in extremely small quantities from the digestive tube into the 
blood, they will be continually burnt in the blood as they arrive, and thus 
they do not require the same amount of motor force as the nitrogenous 
substances, which must permeate the entire organism, to undergo their 
decomposition in the minute tissues. The decomposition of fat and sugar 
develops but little force; there is, however, but little required; and thus, 
although fat and sugar are absorbed into the blood, the proportional rela- 
tions between decomposition and motor force are not disturbed. 



I860.] Teed, Animal Chemistry, and Therapeutics. 81 

If, however, in addition to fat or sugar, nitrogenous food is introduced 
into the blood, the same conditions and results are developed, as before 
stated. The increased supply of plasma increases the decomposition. That 
occasioned by the increase of the plasma is added to that of the fasting 
condition, and at first the increase of the supply will not lessen the conse- 
quent decomposition and wasting of the organs; indeed, each continued 
increase of the supply will, as before, produce a continual increase of the 
decomposition, and a continuance of the waste of the organs, in order to 
liberate the motor force required by the increase of the plasma. But the 
intervention of fat or sugar will place an earlier limit to this proceeding. 
From the use of them less oxygen will be free to maintain the decomposi- 
tion by its influence, and consequently the limits will be the earlier reached, 
where, by continuance of supply, the decomposition will be counterbalanced, 
and finally deposition be induced. This period, as with the use of nitro- 
genous food only, is reached but gradually ; for here also, as the plasma 
and decomposition increase, the decomposition products are increased, and 
they absorb, in addition to the fat and sugar, a larger portion of the oxygen; 
whence it shortly happens that the decomposition is gradually so much 
lessened that the organ gives off no more from its constituents, when, in 
this respect, an equilibrium is produced ; and if the supply be still further 
increased, deposition ensues ; and, indeed, as before said, so much the sooner, 
as the operation of the oxygen is lessened by the presence of fat and sugar. 

The necessary limits are arrived at, as in the preceding sketch, partly by 
the limited capability of absorption of fat and sugar, or else by circum- 
stances which prevent their great accumulation in the blood, the fat being 
removed by deposition, the sugar by the urine. There is also a limit to the 
operation of these substances, arising from an increased affinity on the part 
of the oxygen to the decomposition products of the nitrogenous tissues 
than to the fat or to the sugar taken with the food ; therefore the decom- 
position products and the other oxidizable constituents of the blood are 
always burnt or oxidized the first. Another circumstance which may occur 
with relation to fat and sugar may be, as above mentioned, that these 
substances do not consume so much motor force as the albuminous bodies; 
were the case otherwise, the decomposition would not be lessened by their 
use, since then the force required for their movement would be wanting. 

It will be seen, in the course of the experiments, that the operation of 
the fat may be so developed, as aforesaid, that, when added to an entirely 
nitrogenous diet, in from one-fourth to one-fifth of the entire quantity of 
food necessary, it produces an equilibrium between supply and decompo- 
sition ; and if from one-third to one-fourth, it renders deposition possible. 
If the nitrogenous food be then increased, it is consumed, because its 
increase produces an increase in the decomposition, even in the presence of 
fat. The oxygen does not combine with the fat, but with the decomposition 
No. LXXIX.— July 1860. 6 



82 Teed, Animal Chemistry, and Therapeutics. [July 

products of the nitrogenous organs, for which it has a greater affinity, and 
the fat is deposited. The motor force being supplied by the decomposition 
of the nitrogenous material, the deposition continues, and the decomposition 
being only proportional to the motor force required, with the increase of 
food the decomposition products after a time absorb all the oxygen, all the 
fat is deposited, and the decomposition itself ceases from want of oxygen, 
the motor force fails, and the animal again ceases to eat. 

The subject of volitional movement is next considered, the animal having 
been hitherto supposed to be in a state of rest. The starting-point in the 
whole explanation lies here again in the position that in the organism no 
force is supplied to produce motion but one which is liberated by decompo- 
sition of the respective organs. According to the present state of our 
knowledge, it is impossible that the molecular force to which the organism 
owes its structure and composition can be directly effective as a motor force, 
but there must always be first a decomposition of the material of which the 
moving organs themselves consist ; this molecular force does not forsake 
the matter and change into motor force, and relinquish the matter to other 
forces, but the reverse. The arrangement of the molecules of the matter is 
the operation of its molecular force; it brings and maintains the molecules 
in this arrangement, and to this its operation is limited. Should the matter 
be applied to other uses, as motor or calorific purposes, then the molecules 
of the organic matter must be driven by other molecular forces into another 
arrangement, and then a transfer into motor or calorific force may occur. 
If we, therefore, wish to produce any motor force in the organism, it is 
necessary to cause a decomposition in the material of that organ which 
performs the motion, and our explanation of the circumstances of motion 
must proceed from an explanation of the circumstances of decomposition. 
It is now beyond doubt that the nerves exert this influence. In consequence 
of their action, whether voluntary or otherwise, the decomposition of the 
organ is produced, and force is thereby set free, which now manifests itself 
in movement. We doubt not that this action of the nerves, this influence 
which they exert on the decomposition of the organ in the imparting of 
motion, consists, as it were, in a shock, which alters the arrangement of the 
molecules of the organ. We are of the opinion that this motion in the 
nerves manifests itself, among other things, in an altered grouping of those 
electric molecules of the nerves which we have learned from the admirable 
investigations of Du Bois, when the nerve is in a state of activity. 

The nerve is thus a fourth factor, which operates on the decomposition 
of nitrogenous tissues, besides the oxygen, the plasma, and the bulk of the 
organ itself ; but while the action of the three latter is uninterrupted, that 
of the nerves is temporary, subject to the influence of the will, and appears, 
therefore, to a certain degree, only as one increased, according to circum- 
stances and intention. Yet it is plain that the force which is hereby 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



83 



liberated is used only in volitional movements ; and if, therefore, the force 
necessary for the uninterrupted continuance of the internal movements must 
not fail, then the decomposition of the tissue elements, or of the elements 
of their nutrient supplies, must in a corresponding degree be increased. 

It necessarily follows that, when voluntary movements are produced, the 
relations of all the above-mentioned factors must vary. TVhen the supply 
of food is not sufficient to cover the tissue loss, the body being at rest, an 
additional loss will be incurred in consequence of voluntary movements, 
and a nourishment which would in the former case be sufficient to cover all 
loss will now be insufficient, and the point at which deposition would occur 
be still further removed. The capability of receiving and digesting food 
will be also increased, for we know that these movements accelerate the 
respiration, and increase the absorption of oxygen, which will cause a 
greater decomposition than in a state of rest. 

The further consideration of this subject, and of reflex motions, is beyond 
the range of the present paper. The author only wishes to show how they 
harmonize with his explanations of nutrition. 

It has been already mentioned that animal heat is undoubtedly the result 
of the decomposing effects of atmospheric oxygen in certain organic matter 
— as fat, starch, and sugar — part of which, as fat, is a constituent of the 
body, part, as fat and sugar, are found in the blood, as derivatives of the 
food. The fat, which is already a constituent of the body, and is contained 
in small droplets within nitrogenous cell-walls, is less easily accessible to 
the influence of oxygen than that distributed through the blood, and there- 
fore the attraction of the oxygen will vary accordingly. 

It is not to be supposed that heat can be developed directly from the 
decomposition of the nitrogenous tissue elements, because, if such were the 
case, the application of nitrogenous food and tissue elements to the produc- 
tion of motion would be impossible. But it does not necessarily follow 
that, after this primary decomposition has taken place, the residuary ele- 
ments may not be in part still further decomposed by the oxygen, and from 
this secondary decomposition heat be derived ; this is, on the contrary, 
certainly the case, because these substances are finally expelled as oxides. 
It is thus indubitable that heat is derived from the further oxidation of 
decomposition products of nitrogenous matters, both of the body and of 
the food. The relative affinity between the oxygen and the former of these 
is best seen in a condition of hunger. 

The proportion in which the tissues are decomposed and their products 
still further consumed, and in which the fat of the body is also invaded r 
shows the degree of the affinities which are here in operation. It is in this 
case, however, most important to remember that they are not perfectly 
represented; that is, although the oxygen has a much greater affinity to 
the fat than to nitrogenous substances, the decomposition of these latter is 



84 Teed, Animal Chemistry, and Therapeutics. [July 

not prevented, the oxygen not combining entirely with the fat ; the causes 
of which are evident — partly through the liability to decomposition of 
nitrogenous tissue elements, through the pressure and attraction of the 
plasma, partly because the fat is not distributed through the blood, but is 
contained in nitrogenous cell-walls. When, however, this is not the case, 
as when we feed an animal fat, so that the fat is found in the blood, nitro- 
genous tissue is always decomposed, a proof that even here the attraction 
of oxygen to it and its decomposition products is greater than even to the 
free fat in the blood. 

The oxygen, therefore, first produces the decomposition of nitrogenous 
matter with the assistance of the plasma, and then, by further combination 
with decomposition products, develops heat. What oxygen remains above 
this operation, when the resistance on the part of the nitrogenous tissue is 
increased, combines with the free or deposited fat, and sooner, with the 
former than the latter. 

But as the resistance of the nitrogenous tissues to oxygen is dependent 
on the bulk of the organ and the quantity of plasma, and is diminished by 
the increase of this latter, it is evident that the amount of oxygen capable 
of uniting with the fat will depend on the bulk of the nitrogenous tissues, 
and principally on the amount of the plasma ; for as the latter increases, 
the decomposition increases, decomposition products are more abundant, 
these absorb more oxygen, and less remains for combination with the fat. 
This may continue until all the oxygen is consumed by the nitrogenous 
elements of the tissues and food, and all the heat is developed from these 
decomposition products. The fat is then no longer consumed, even when 
it is free in the blood ; it is therefore deposited. Whether sugar, in such 
cases, is converted into fat and deposited, we must at present leave unde- 
cided, since we cannot, as in the case of fat, speak of its general relations 
:and attractions towards oxygen ; but, from our experiments, we may here 
remark that in carnivora the circumstances are never such that all the 
sugar is either consumed, or excreted in the urine. 

There is thus a condition in the nutrition of an animal when the whole 
•of its heat is derived from its nitrogenous food, yet never from its direct 
oxidation in the blood, but always as a result of the decomposition of the 
nitrogenous tissues. There is, therefore, no " luxus consumption" or oxida- 
tion of albumen in the blood, as Frerichs and Schmidt affirm. But since 
this large consumption of nitrogenous tissue and food in the body of an 
animal, whereby all its heat is also supplied, is not necessary to its exist- 
ence since the force which is thereby developed is used only for the move- 
ment of this mass of food, the heat which is thereby formed as a secondary 
product is much preferably produced by the use of other matters, as fat and 
sugar; and this excessive use of flesh is a great "luxus consumption," 
which can and ought to be prevented by the due use of non-nitrogenous 
substances. 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



35 



We thus see the principles which have been deduced from the various 
experiments detailed more fully in the work. The question as to whether 
urea is or is not the sole nitrogenous product of tissue-change in carnivora 
lies at the foundation of all his arguments, and of all his experiments also. 
The dog, on which these experiments were carried on, was fed in various 
ways, having been first examined in a fasting condition to obtain a basis 
for further investigations. The dog was carefully weighed every morning, 
as were also his food, drink, and excrements, and his urine measured; this 
last he was trained to pass every morning into a glass vessel. It was then 
tested for urea by Liebig's method of trituration by nitrate of mercury, and 
for sulphuric acid by baryta, the nitrogenous contents of the food, and also 
of the excrements were also ascertained, and the calculation made as to the 
gain or loss of tissue accordingly; the amount of fat or water given off or 
deposited was calculated from the amount of oxygen inspired, and from the 
amount of animal heat liberated by the combustion of the carbon and hy- 
drogen. The experiments were conducted with the greatest care, and 
deserve attentive consideration. 

The first series of experiments are on the tissue-change in the fasting 
condition. 

From October 19 to 25, the dog was kept without food, but on the 23d 
he drank 63 grm. 1 of water. He weighed, on Oct. 19, 33,310 grm., on Oct. 
25, only 30,330 grm., he thus lost 2980 grm. He excreted 1130 c. c. of 
urine weighing 1186 grm., which contained 121.558 grm. of urea, equal in 
nitrogen to 56.13 grm. ; this represents 1668 grm. of flesh, which must have 
been derived from his own body ; besides this, he lost 1312 grm. of fat or 
water, or of both. 

Doubtless this loss was fat only, for if it were water the material indis- 
pensably necessary for respiration and the maintenance of heat would be 
wanting. According to Reynault and Reiset, a dog of this weight would 
consume daily about 250 grm. of carbon, and 900 grm. of oxygen. If the 
dog had had only the carbon from the above calculated flesh, 1668 grm., 
it would not have amounted to 40 grm. in the 24 hours ; while reckoning 
the remaining loss as fat, he would have 180 grm. of carbon as his supply. 
So with this amount of flesh he would have had only 100 grm. of oxygen 
daily, while the additional fat would give him 644 grm. The well-known 
fact that fasting animals lose their fat argues further in favour of the loss 
being fat, while there is no ground to suppose that the dog would give off 
water while as much water as he desired was at his disposal. 

But the calculation of the excretion from the kidneys, skin, and lungs, 
show that the dog needed no more water than would be formed from the 
flesh and the hydrogen of the fat. 

1 In all these experiments grm. is used to signify grammes, the French decimal 
weight of 15 J grs. nearly. 



86 Teed, Animal Chemistry, and Therapeutics. [July 



The following table gives us the calculation : — 



INGESTA. 


Food. 


Water. 


N. 


c. 


H. 


0. 


1668 grm. of his own flesh. . 
1312 fat tissue with 1128.3 of fat 
Water drunk .... 


1266.0 

183.7 
63.0 


56.73 


208.8 
891.3 


28.86 
124.10 


85.9 
112.8 


1512.7 


56.73 


1100.1 


152.96 


198.7 


EGESTA. 


1130 c. m. urine 

There remains for lungs and skin 


1048.0 


56.73 


24.4 


8.20 


32.6 
166.1 


464.7 




1075.7 


144.76 



The 144.16 H. are equal to 1302.8 water, therefore he excreted by the 
lungs and skin 1167. 5 water, and 1015.7 grm. of carbon. 

In order to prove the correctness of our calculation founded on this con- 
sumption of nitrogen we use the computation of the relative loss by the 
skin and lungs, as a proof thus — 

The dog consumed from his body . . . . . 2980 grm. 
" " water . .- . . . 63 " 

3043 " 

He evacuated 1130 c. c. of urine .... 1186 " 

There remain for skin and lungs . . . . 1857 " 
Our reckoning above gives 1851 " 

The amount of animal heat generated gives us another proof ; for every 
1 grm. of carbon 8086 units, and for every 1 grm. of hydrogen 34,462 
units of heat are generated according to the researches of Yon Favre and 
Silbermann ; but as the 166.1 grm. of oxygen would combine with 20.1 grm. 
of the hydrogen, there would be left 124.06 grm. of hydrogen and 1015.1 
grm. of carbon to be oxidized ; these would yield 12,916,466 units of heat, 
or for each 24 hours 2,162,144 units. 

A second experiment of three days yields similar results. A third of 
seven days immediately following a seven days very high feeding with flesh 
and fat agrees in general with the others, with some variations arising from 
the different condition of the dog. A fourth and fifth relate to single days 
of fasting, agreeing closely with one another and with the general results. 

The second series, containing fourteen experiments, relate to feeding on 
flesh only. 

The flesh was fresh lean beef very carefully freed from fat, cartilage, 
bone, &c. ; this contained, as shown by numerous analyses, only one per 
cent, of fat. 



I860.] Teed, Animal Chemistry, and Therapeutics. 87 



The first seven experiments cover nineteen consecutive days, in which 
the dog was fed for seven days on 1800 grm. of flesh, which was reduced 
every third day until it reached 176 grm. only, as shown in the following 
table : — 

Table of Flesh Feeding. 



Date. 


Weight, grm. 


Food, grm. 


Water, cm. 


Urine, cm. and grm. 


Urea, grm. 


Feces, grm. 






Flesh. 




Cub cm. 


Grm. 






Nov. 9 


34410 


1800 


213 


1751 


1798 


86.850 




10 


34100 


1800 


5 


1428 


1486 


118.524 




11 


33990 


1800 


310 


1599 


1663 


131.756 


17.6 


12 


34020 


1800 


137 


1313 


1372 


120.796 




13 


34200 


1800 


340 


1401 


1465 


131.694 


16.2 


14 


34460 


1800 


18 


1185 


1244 


1 OO l"7l A 

lZo.714 




15 


34610 


1800 


120 


1213 


1272 


123.626 




16 


34850 


12600 


1143 


9890 


10300 


847.059 




16 


34850 


1500 


10 


990 


1039 


108.50 


~l CtO C\ 

loo. 9 


17 


34810 


1500 


10 


1003 


1055 


108.12 




18 


34910 


3000 


20 


1993 


2094 


216.62 


163.9 


lb 


OA m A 


1200 




830 


872 


89.81 




19 


34910 


1200 




809 


851 


87.37 




20 


34930 


2400 




1639 


1723 


177.18 




OA 


O A no A 

34930 


900 




571 


705 


o9.784 




21 


34780 


900 




615 


647 


65.805 




22 


34710 


1800 




1186 


1352 


135.589 




22 


34710 


600 




465 


489 


49.848 




23 


34490 


600 




450 


474 


48.150 




24 


34320 


1200 




915 


963 


97.998 




24 


34320 


300 




320 


337 


32.640 




25 


33970 


300 




317 


333 


32.651 




26 


33660 


600 




637 


670 


65.291 




26 


33660 


176 




274 


288 


27.400 




27 


33270 


176 




258 


271 


26.212 




28 


32850 


352 




532 


559 


53.612 





December 1, the dog fasting, lie discharged 24,213 grm. of feces. 

To every 100 grm. of flesh fed there correspond nearly 1.85 grm. of feces. 



In examining the first experiment of seven days there were 33.8 grm. of 
feces remaining in the dog from his previous food, and as the quantity of 
meat fed would yield 233 grm. of feces, the dog gained only 241 grm. 

The 12,600 grm. of flesh contained 428.4 nitrogen. The 847.059 grm. 
of urea contained 395.32 grm. N. The 233 grm. feces were composed of 
44.4 percent, of solids, or in the whole of 103.45 grm. of solids and 129.55 



88 Teed, Animal Chemistry, and Therapeutics. [July 

of water. The solids contained 6.5 per cent, of nitrogen. The urea and feces 
contained, therefore, 402.04 grin. N., showing a gain of 26.36 N., equal to 
Tt5 grm. of flesh. These were deposited; but as the dog gained only 241 
grm. he must have given off 534 grm. of fat or water. It was doubtless 
water, because the amount of carbon and hydrogen in the 1800 grm. of 
flesh were sufficient for the necessities of respiration, and because for the 
first four days he lost weight and the urine was very watery. 
The following calculation is appended : — 



INGESTA. 


Food. 


Water. 


*. 


c. 


H. 


0. 


11,825 grm. of flesh 

Water drunk .... 

Water given off 


8975.17 
1143 

534 


402.05 


1480.49 


204.57 


608.99 


10652.17 










EGESTA. 


9890 c. c. urine 

233 grm. feces .... 

There remain for skin and lungs 
141.47 H. = . 


9323.00 
129.55 


395.23 
6.72 


169.41 
44.94 


54.41 

6.69 


226.91 
13.22 


9452.55 
1199.62 
1273.23 


401.95 


214.35 
1266.14 


63.10 
141.47 


240.13 
368.86 


2472.85 


! 







The proof — 

The dog consumed in flesh ..... 12,600 grm. 

" « water . . ' . . . 1,143 " 



13,743 " 

He excreted in 9890 c. c. urine .... 10,300 " 

Feces 34 " 

Increase in weight 440 " 

10,774 " 

There remain for skin and lungs .... 2,969 " 
Our reckoning gives 2,977 " 

From this we learn that the 1800 grm. of flesh were sufficient to nourish 
the dog in all respects ; that at first, when the dog had been previously fed 
on bread, he was poor in nitrogenous elements, and at first he lost weight 
by exchanging other matters which he gave off for flesh which he deposited. 
The respiratory requirements and the heat were not fully met by the above 
calculation; the flesh consumed would give only 1,932,043 units of heat, 
while we have seen that in the fasting condition 2,200,000 were about the 
minimum, wherefore he must have lost, during the first day, about 80 grm. 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



89 



of fat, depositing 608 grm. of flesh according to the difference between the 
nitrogen taken in the food and excreted in the urea. A great excretion of 
water took place on the first three days, in which the dog continually lost 
in weight. On the first day he must have lost 838 grm. of water, the body 
having been very full of water from the previous feeding with bread. 

TTe see also that the three chief ingredients of the body, the nitrogenous 
tissues, the fat, and the water, bear certain proportional relations to one 
another, and to the alterations in the weight of the body. 

The calculations for the rest of this series can be easily made from the 
accompanying table; they show no variation from the general principles 
laid down. The remaining seven experiments under this head relate to 
large quantities of flesh food, the results, however, are similar in all respects 
to the above. 

The third series of nineteen experiments were made with feeding flesh and 
fat, and fat alone ; the flesh was prepared as before ; the fat was pure melted 
butter. 

In the first experiment the dog was fed 150 grm. flesh, and 250 grm. fat 
for ten days, in which he lost only 161 grm., but as he gave off 830.3 grm. 
nitrogenous tissue he must have deposited 669.3 grm. of fat or water, or 
575.6 grm. fat-tissue with 93.7 water. 

In a thirty-one days' feeding with 500 grm. flesh and 250 fat, the dog 
gained 4543 grm., composed of 1794 grm. flesh, 2364.14 fat-tissue, and 
384.86 water. 

Several experiments follow of variable quantities of flesh combined with 
250 and 150 grm. of fat ; thus, 1000, 1500, 1800, 2000 grm. of flesh with 
250 grm. fat, and 1500, 1000, 700, and 400 grm. of flesh with 150 grm. 
fat ; the first set show that the dog deposited flesh and fat, and continually 
gave off water; in the second set, although the food continually diminished 
in quantity, the weight of the body remained nearly the same, the dog con- 
tinually giving off his nitrogenous elements, the N. in the urea being always 
more than that contained in the food, he therefore deposited water. But 
the action of the fat in preserving the nitrogenous tissues is shown in the 
fact, that, while the food sank from 1500, as above, to 400 grm., the nitro- 
genous decomposition increased only from 8 to 23, 77, and 81 ; the effects 
of the same quantity of fat were seen most strongly when combined with 
the smallest quantity of food, because the larger quantity of food would of 
itself cause an increased decomposition ; with this would arise an increase 
of decomposition products, which, by absorbing oxygen, would render a 
deposition of fat necessary ; but as the amount of the food was lessened 
there was sufficient oxygen not only for all the decomposition products and 
the fat, but also for a certain amount of the constituents of the body. 
When the fat began to be insufficient to render a deposit of flesh or fat 
possible the dog began to drink water, which he had before refused. 

In three days' feeding with 500 grm. flesh and 200 grm. fat per day, the 



90 



Teed, Animal Chemistry, and Therapeutics. 



dog gained 304 grm., the N. -of the flesh, and of the urea and feces, equalled 
one another, the deposit would be 261 fat, 48 water. 

In three days' feeding with 500 grm. flesh, and 300 grm. fat, he gained 
354 grm., as the X. excreted was less than that contained in the food the 
gain was 132 grm. flesh, 190.92 fat, and 31.08 water. 

Four days' feeding with 500 grm. flesh alone showed a loss of 754 grm., 
which, from the excess of N. excreted, should be divided into 88 grm. flesh, 
572.76 grm. fat, and 93.42 water. 

Three days' feeding with 1500 grm. flesh and 350 fat caused a gain of 
962 grm., of which 159 grm. were flesh, 690.6 fat, and 112.4 water. 

Two days' feeding with 330 and 350 grm. fat only showed a loss of 100 
grm., but as the X. excreted was considerable, while none was taken in 
the food, the calculation would be loss of flesh from the body 410 grm., de- 
posit of fat 266.6, of water 43.4 grm., the loss of nitrogenous tissue exceed- 
ing the loss of total weight by 310 grm. 

The fourth division comprises feeding with flesh and sugar, and sugar only, 
and contains eleven experiments; the sugar used was grape and milk sugar. 

The first experiment is shown in the following table: — 



1 

Date. 


Weight, 


Flesh. 


Sugar. 


Water. 


Urine. 


Urea. 


Feces. ' 












C C. 


Grm. 






■ Nov. 16 


28670 


150 


100 


415 


190 


197 


13.680 


201.8 


17 


28610 


150 


150 


95 


185 


193 


13.690 




18 


28500 


150 


250 


107 


156 


164 


13.104 




19 


28520 


150 


350 


185 


148 


156 


13.616 


141.4 


20 


28520 


150 


350 


200 


240 


248 


13.440 




21 


28620 


150 


350 


154 


260 


268 


13.000 


103.6 


22 


28480 


900 


1550 


1216 


1179 


1228 


80.530 


446.8 



Calculating the relative proportions of feces the dog lost 117 grm. He 
excreted X". equal to 444 grm. flesh more than he received, and must have 
deposited water to the amount of 327 grm. The feces consisted of 271.39 
water and 102.41 solids, but contained no sugar. 

In a second experiment the flesh and sugar were respectively 750 and 
150, 500 and 200, 300 and 250, 300 and 250, 150 and 300, 200 and 300, 
the first number being flesh, the second sugar ; the dog remained of the 
same gross weight, but, calculating the feces derived from the food and 
still retained, he lost 172 grm. He excreted N". equal to ^79 grm. flesh 
more than he received, but, as his weight was only 172 grm. less, he must 
have deposited 607 grm. of water. It could not have been fat, because the 
carbon necessary for excretion by the lungs and skin would have been 
deficient. , 

With large quantities of flesh and sugar he gained in weight, thus with 
2000 grm. flesh, and 200 of grape sugar, he gained 193 grm. ; but, as he 
deposited N. equal to 320 grm. of flesh, he must have given off 127 grm. 



I860.] Teed, Animal Chemistry, and Therapeutics. 91 

water. "With 2000 grm. flesh, and 100, 200, and 200 of milk sugar, he 
gained 546 grm. He deposited 600 grm. flesh, and gave off 54 grm. water. 
A series of five experiments give the following results: — 

Fed on The consumption was 

500 grm. flesh. 564 flesh. 161 fat. 

500 flesh. 250 fat. 557 " 175 " 

500 " 100 sugar. 537 " 151 " 100 sugar. 

500 " 200 " 500 " 76 " 200 " 

500 " 300 " 466 " 34 " 300 " 

From this we see the nitrogenous decomposition was greatest with flesh 
alone ; that fat reduced this less than sugar ; that the influence of the sugar 
was proportional to its quantity; that the fat besides reducing the nitro- 
genous decomposition caused a saving of the fat of the body, although 14 
grm. more of the fat fed were consumed than previously of the body fat; 
that the sugar took the place of the body fat and of the fat in the food, 
yet 300 grm. of sugar were not sufficient to prevent the consumption of 
some of the body fat ; 100 grm. sugar saved 20 grm. body fat, and 24 grm. 
of the fat of the food; 200 sugar, 85 and 99; and 300 sugar, 12? and 144 
of the body fat and food fat respectively. 

It follows that fat and sugar have an inverse influence on nitrogenous 
decomposition and the respiratory process. The fat, from containing two 
and a half times as much carbon and hydrogen as sugar, is more effective 
in the respiratory process, while sugar is more powerful in reducing nitro- 
genous decomposition. The fat and sugar both act by absorbing oxygen, 
and so reducing its influence. According to their composition the fat should 
be more effective than the sugar ; the contrary, however, is the case, because 
the sugar more readily combines with the oxygen, absorbing it directly, 
while the fat has to take part in the general tissue decomposition previously. 
The action of the sugar is more direct and immediate, and lessens the nitro- 
genous decomposition more than fat from not requiring so much motor force. 

In one experiment of two days, in which the dog was fed with. 37. and 
500 grm. of grape sugar, he lost 368 grm. He excreted K equal to 494 
grm. of flesh, and therefore deposited 126 grm. water. In comparing this 
with an experiment in which he was fed on fat only, being in both cases of 
the same weight and in equally good condition, we observe that in this case 
he consumed, daily, 247 grm. flesh and 430 grm. sugar ; in the other, 196.5 
grm. flesh and 196.8 grm. fat. Thus 100 grm. sugar reduced the nitro- 
genous decomposition as much as 100 grm. of fat, or, considering their 
respective proportions of carbon and hydrogen, two and a half times more. 

The next division treats of feeding on flesh and starch, and starch alone. 

The starch was mixed with fat and salt into a kind of cake, which was 
baked. This the dog would eat only in small quantities, and for a short 
time ; to have given it in larger quantities it would have been necessary to 
have crammed him. 



92 Teed, Animal Chemistry, and Therapeutics. [July 



The first experiment was continued for eleven days, in which the same of 
flesh, 1*76 grm., was given daily; the starch and fat varying from 100 to 
364 for starch, and from 9.1 to 29.6 for fat. The total loss in weight, 
after calculating the feces, was 33 grm. He excreted nitrogen in excess, 
equal to 484 grm. flesh, and therefore deposited 451 grm. of water. It is 
evident that IT 6 grm. flesh, with any quantity of starch, was not sufficient 
to cover the nitrogenous decomposition, the average amount of which was 
206 grm. daily ; although the starch had considerable influence in reducing 
it, as may be seen by comparing the loss when 1T6 grm. flesh alone were 
used. The quantity of starch, however, exerts some, though only a slight, 
influence on it, for the amount of urea was less when the greatest quantity 
of starch was fed, and the reverse. With 150 grm. starch 66.5 grm. flesh 
were given off, with 364 grm. starch only 23 grm. flesh; so with 150 grm. 
starch 96 grm. of body fat were given off, with 364 grm. starch only 18. 

In a second experiment of eleven days the flesh was reduced from TOO to 
150 grm., while the starch was increased from 150 to 430 grm., and the 
fat from 11.5 to 20 grm. The dog, however, lost 335 grm. in weight; he 
excreted nitrogen in excess, equal to 1,309 grm. of flesh, and therefore must 
have deposited 9T4 grm. water. In a five days' feeding, with 2,000 grm. 
flesh daily, and 200 grm. of starch for two days and 300 for three days, 
with about 5 grm. of fat daily, he gained in weight 1,28T grm., of which 
1,041 were flesh and 246 water. A five days' feeding with 500 grm. flesh, 
250 fat, and 250 sugar, resulted in a gain of 639 grm. ; but as he excreted 
nitrogen in excess, equal to 295 grm. flesh, he must have deposited 934 of 
fat or water, or both — thus, 803.24 fat, and 136. 1 6 water. 

When fed for three days with 100, 200, and 360 grm. of starch, with 22, 
23, and 40 of fat, he lost 90 grm., and gave off nitrogen equal to 52T grm. 
of flesh, and therefore deposited 43T grm. water. Two days' feeding with 
450 grm. starch and 19.T of fat resulted in the weight of the dog remaining 
the same; but as he excreted 334 grm. of flesh in nitrogen of the urea, he 
must have deposited 334 of water. 

The next division relates to feeding with bread only, with two experi- 
ments. The first, of six days' feeding with from 6T8.8 to 999.7 grm. of 
bread, which were again reduced to 730 grm., showed a loss of 296 grm., 
with an excessive excretion of nitrogen, equal to 924 grm. flesh, with con- 
sequent deposit of 628 grm. water. 

In forty-one days' feeding with bread, in very variable quantities, just 
what he chose to eat, from 1,091 to 263 grm., the dog lost 531 grm. ; he 
excreted nitrogen in excess, equal to 3,717 grm. flesh, and consequently 
deposited 3,186 grm. water. 

The seventh and last series of nine experiments relate to feeding on flesh 
and gelatin, fat and gelatin, and gelatin alone. 

The gelatin used was the fine French glue, in thin, clear yellow plates ; 
this was dried in an air-bath, and then weighed ; then covered with hot 



I860.] Teed, Animal Chemistry, and Therapeutics. 



93 



water and allowed to stand all night, and again weighed, when the contained 
water was estimated. The dog ate this jelly at first in small quantities, and 
very readily when mixed with flesh. The quantity of flesh fed was about 
equal to the nitrogenous decomposition in the fasting condition. The 
results of the first experiment are shown in the following table : — 



Date. 


Weight. 


Flesh. 


Glue. 


Water. 


Urine. 


Urea. 


Feces. 


May 1 


40500 


1100 


100 


160 


1084 


1133 


110.57 




2 


40400 


1200 


100 


93 


983 


1032 


112.06 




3 


40430 


800 


200 


257 


957 


1005 


112.46 




4 


40380 


400 


300 


288 


895 


937 


110.98 




5 


40110 


400 


300 


543 


916 


960 


100.92 




6 


40000 


3900 


1000 


1341 


4835 


5067 


555.99 





Calculating the feces, the loss in weight is 590 grm. He received in 
flesh and glue 273.1 nitrogen, and excreted in the urea and retained feces 
(90 grm.) 262.0 nitrogen, being 11.02 grm. less nitrogen than he received; 
these are equal to 324 grm. of flesh, which he deposited; but as he was 390 
grm. lighter, he must have given off 914 grm. water and fat. 

On the first day the nitrogen received and given off was equal ; there was 
also some fat given off to support animal heat, and some water. 

On the second day 76 grm. flesh were deposited, and fat was given off as 
before. 

On the third day 87 grm. flesh were deposited, but he lost 131 grm. in 
weight; he must, therefore, have given off fat and water. 

On the fourth and fifth days he deposited 100 grm. of flesh in each, but 
gave off on the fourth day less fat and more water, on the fifth more fat 
and less water. 

It is evident from the results of this experiment that the gelatin lessens 
the nitrogenous decomposition, and the necessity for nitrogenous, i. e. flesh, 
diet. We thus see that the use of 400 grm. flesh, which had previously 
caused no deposit of flesh, even with the addition of fat, when combined 
with 300 grm. of glue occasioned a considerable flesh deposit, although at 
the same time fat was given off ; and this is rather remarkable, because its 
conversion into respiratory material cannot account for it, since it contains 
so much oxygen that it can yield but little carbon and hydrogen for further 
combustion. The feeding of fat, as we have seen, protects only a small 
amount of the nitrogenous food from decomposition, and thus promotes its 
deposit. Glue must have a special action, and it is manifest that its quan- 
tity is very important, for a thrice larger quantity of glue, with a thrice 
less quantity of flesh, produced a considerable deposit, which did not occur 
when the proportions of flesh and glue were reversed. We must, therefore, 
consider that the glue is assimilated, and performed a part of that work for 



94 



Teed, Animal Chemistry, and Therapeutics. 



[J"iy 



which the albumen of the food would have been otherwise employed, so 
that a portion of this latter could be deposited. 

In the second experiment, of three days' feeding with 200 grm. of flesh 
and 200 of glue daily, the total loss was 1,405 grm. — 135 grm. flesh, 330 
fat, and 341 water. 

A third experiment, of two days' feeding with 200 grm. flesh and 300 
glue, gave as the loss 353 grm. — 154 flesh, 190 fat, and 9 water. 

This last experiment presents one point of great interest; for as we have 
just seen that when 200 grm. of flesh and 200 of glue were fed, so much 
nitrogen was excreted as to require a decomposition of 245 grm. of the 
flesh of the body, by the addition of 100 grm. of glue this was covered up 
to 17 grm. This agrees with the former experiments, and confirms our 
main proposition that all the nitrogen, or the greatest part of it, contained 
in the food is evacuated in the form of urea. With 200 grm. of flesh and 
200 of glue 245 grm. of body flesh were required, with 200 grm. flesh and 
300 glue only 11 grm. ; 100 grm. glue are therefore equal to 168 grm. of 
flesh. 

Three days' feeding with 500 grm. flesh and 200 of glue were followed 
by a gain of 316 grm., of which 134 were flesh and 182 water. When we 
compute the amount of heat formed, we find it necessary to reckon some 
fat as having been given off. The daily consumption would then be 455 
grm. flesh, 20 glue, and 108 fat. 

With 2,000 grm. flesh and 200 glue, fed daily for three days, the gain 
was 562 grm. Computing the nitrogen, there were 652 grm. flesh depo- 
sited, and consequently 90 grm. of water or fat given off. We here see 
that a large increase of flesh food caused a great increase in the decompo- 
sition; but we have seen previously that when fed on 2,000 grm. flesh alone 
he decomposed the whole, with 2,000 grm. flesh and 250 fat he deposited 
only 118 grm. Now, with the same quantity of flesh and 200 glue he 
deposited daily 211 grm. That this was not accomplished by an attraction 
of the glue directly for the oxygen is shown by the abundance of the de- 
composition products, and the amount of heat developed is considerably 
more than what was taken as the minimum in the fasting condition. 

Three days' feeding with 200 grm. glue alone daily, gave a loss of 624 
grm. — 249 flesh, 322.5 fat, and 52.5 water; a loss of only 83 grm. flesh 
daily, an effect not produced by 340 grm. of fat. 

Three days' feeding with 200 grm. glue and 200 fat gave a loss of only 
94 grm., while 158 grm. of flesh were excreted in the nitrogen of the urea; 
there must, therefore, have been a deposit of 55 grm. fat, and 9 water. 

Feeding for three days with 50 grm. of glue and 200 of fat gave a loss 
of 561 grm., with an excretion of nitrogen in excess equal to 593 grm. of 
flesh; this was derived from the body; but 32 fat-tissue were deposited, 
consisting of 21.52 fat and 4.48 water. 

Three days' feeding with 100 grm. glue and 200 fat gave a loss of 849 



I860.] Teed, Animal Chemistry, and Therapeutics. 



95 



grm — 310 grm. of flesh, and 549 grm. most probably of water, from the 
amount of fat in the food. 

If we compare the last three experiments, we shall see that with the use 
of 50 grm. glue, 200 grm. flesh were given off from the body. With 100 
grm. glue fed, 100 grm. flesh were given off; and with 200 grm. glue, only 
50 grm. flesh were lost; thus there is a direct proportion between them; 
but as the flesh contains three times more water than the glue, one part of 
flesh operates equally to four parts of glue. If, therefore, the dog had 
consumed 250 grm. of glue, no further loss of flesh would have been sus- 
tained. The reason why gelatin proves an insufficient nourishment is that 
such large quantities of it are required to replace the albumen — at least 
four times as much glue as dried flesh, or as much dry glue as moist flesh. 
The animals, consequently, will not consume it. The reason why, when 
animals have been previously fed with glue, they have died, is twofold — 
first, they could not eat enough of it to cover their nitrogenous loss; and 
secondly, because, after the consumption of all their fat, they had no longer 
the means of producing animal heat. 

The glue used in these experiments may be very much better than ordi- 
nary glue. This French glue, apparently, contains more chondrin, and it 
may perhaps contain some albumen ; this seems to be the case, from its 
containing less nitrogen and more sulphur than common glue. 

The results of these experiments may be thus briefly stated : — 

In the fasting condition* an animal continually loses flesh and fat, as urea, 
carbonic acid, and water ; and this loss is in proportion to his bulk. 

In feeding with flesh alone, an animal requires from ^ to ^ of his 
weight daily to maintain his condition ; and as soon as he begins to 
deposit flesh he will consequently require his food to be proportionally 
increased ; and this may continue until the animal has reached his maxi- 
mum, and then he ceases for awhile to eat ; the increase in the food causing 
a retention of his fat. 

In feeding with flesh and fat, and with fat alone, we learn that fat is not 
sufficient to prevent nitrogenous decomposition ; nor yet to prevent its 
increase when the food is increased. Moreover, the fat itself causes an 
increase in the nitrogenous decomposition ; but it lessens the relative 
amount, i. e. less nitrogenous matter is decomposed if fat be used, than 
would be if it were not : thus ^ to J- of the nitrogenous food will, if com- 
bined with fat, be sufficient to keep an animal in condition, to what would 
be sufficient without fat, and the administration of fat in the food not only 
saves the fat in the body, but causes more to be deposited. Sugar has a 
similar effect to fat, only more powerful ; it cannot prevent the nitrogenous 
decomposition, nor its increase under increased feeding, nor the influence of 
the increased bulk of the organs. It acts only relatively, and by its use 
induces an. earlier deposition of the flesh and fat contained in the food than 
would occur without it. As carnivora cannot be induced to take enough 



96 



Teed, Animal Chemistry, and Therapeutics. 



[July 



sugar to supply all their wants in internal motion and heat from nitrogen- 
ous decomposition, the sugar can never be deposited as fat ; and, indeed, in 
any case this does not seem probable. 

The effects of starch are similar to those of sugar, and in carnivora bread 
does not afford a full force-sustaining nourishment. 

A more important character must be assigned to gelatin than has been 
previously attributed to it. It possesses the power of lessening the con- 
sumption of albumen — four parts of glue being equal to one of albumen. 
It cannot, however, be taken in quantity sufficient to cover the whole of the 
albuminous consumption. From these facts Liebig's division of food into 
plastic and respiratory are considerably strengthened. As, however, all 
depends on the truth of the proposition that all the nitrogen is excreted as 
urea, and that this is derived from tissue change only, in experimenting for 
this purpose this is the first point to be ascertained ; this can easily be 
done by varying the weight of food and observing the variations in the 
amount of urea. 

With regard to herbivora there are doubtless many variations, among 
others the formation of fat from carbo-hydrates. 

The only important thing, however, in all these inquiries is to ascertain 
the processes which occur in man. The first step to be ascertained is in 
what condition he excretes nitrogen in urea only, and in what other form, 
if any. Experiment alone can determine this. One thing, however, is 
certain, that the so-called ''normal diets," and the "equalizations of food," 
which have been hitherto founded on general rules, are of no use at all, as 
affording any guide in any particular individual case. Each one is a law 
only to himself, and varying circumstances will cause such variations in 
every individual that a special calculation will be required to meet them. 
The stronger the man the more food will he require to maintain his strength 
than a weaker man, the exercise of both being equal. 

The bulk of the organ, the amount of the plasma, that of the disposable 
oxygen, and the energy of the nerves constitute the four great factors in 
the acts of decomposition ; these are always equal to one another, or are 
striving for an equality, in which the force needed for motion and the 
animal heat are liberated. 

In an appendix are some remarks on the urine and feces, and some ana- 
lytical tables. 

In presenting this abstract of Bischoff and Voit's treatise, we have de- 
parted from our original intention, and we trust not unacceptably to the 
reader. The importance of the subject, the small probability of such a 
treatise being translated, and the fact that it is, in its original, out of the 
reading of a large number of the profession, are our reasons for this change. 
The doctrines herein taught, although we cannot agree with all his conclu- 
sions, yet, taken as a whole, give a much clearer insight into many of the 
conditions of diseases from malnutrition in their earlier stages than we 



I860.] 



Teed, Animal Chemistry, and Therapeutics. 



97 



previously had. The rapidity with which the blood and tissues exchange 
their solids for water, coupled with the fact mentioned by Ricord on one 
side, that in cases of enlarged lymphatic glands the blood is always watery; 
and on the other side with the notorious connection between lymphatic 
glandular enlargements and phthisis or scrofula, advance our knowledge 
one step, if only a short one, in the comprehension of this subject. Thus, 
we see a child in apparently good condition, i. e. plump, and yet here are 
these incipient scrofulous developments — the condition of the child becomes 
so much more intelligible, and the indications of treatment so much the 
better grounded. Nor can it be too strongly impressed on the mind of the 
parents of every such child that dietetics must be the chief means to be 
depended upon to protect the child from further developments. While 
with the profession the more minute the study into the earliest symptoms, 
or the predisposing causes of this scourge, the greater will be the possibility 
of averting its destructive progress. The profession has been too long 
engaged about the means of its cure, to pay much attention to those of its 
prevention, or of its arrest. One specific is vaunted after another, to 
receive the same summary dismissal ; and thus the investigation into prin- 
ciples has been neglected, from which alone we can with reasonable hope 
expect success. 

The view promulgated by Liebig, that the alkaline carbonates contained 
in the blood are the carriers of carbonic acid out of the system to the lungs,, 
where it becomes disengaged, and the opinion that the globules are the 
main carriers of oxygen into the system, have received strong confirmation 
from the researches of M. Fernet ; he found also that the absorption of 
oxygen by the serum was in inverse proportion to the amount of salines 
present. Consequently, where the salines are in excess, and the globules 
deficient, a very large deficiency of oxygen in the system would so reduce 
one of the factors of tissue change — to say nothing of a second, the nerve 
force — that the whole internal workings would be deranged, the assimi- 
lating organs would have no material with which to do their work, the 
excretory organs would be overtaxed, the nitrogenous decomposition would 
sink very low, and consequently the need of supply would cease, effete matter 
would be long retained in the tissues, the result of this cessation of tissue 
change, and a faulty structure would result, which will be only ready to 
decay: the frequent complication of anseniia and chlorosis with phthisis, 
and the great preventive of, and remedy for, this disease, fresh air, and 
increased respiration of oxygen, combined with a nitrogenous or blood-cor- 
puscle making diet, witness to the correctness of these views, for even when 
the fat "cod-liver oil" is beneficial, the appetite is increased and the powers 
of assimilation strengthened. But we have need of a much enlarged con- 
ception of the minutiae to make our views practically applicable to the larger 
number of cases, and an acquaintance with nutrition in health must precede 
that of nutrition in disease. 

No. LXXIX— July 1860. T 



98 Teed, Animal Chemistry, and Therapeutics. [July 

Another point against which we cannot too strongly urge, is the "doc- 
trine of averages," and its twin sister, the "numerical method." In nature 
there never was, nor is, nor ever will be such an anomaly as an average. 
Everything is the absolute and certain result of fixed and definite causes. 
Alter these in any way, even to the least degree, and the results vary 
accordingly and in a fixed and certain proportion. She knows no "me- 
dium ;" she knows nothing but a unit ; and this unit is a combination of 
facts, varying in each, and therefore originating results varying correspond- 
ingly — experimentation therefore, and the accumulation of facts, can alone 
furnish us with the key to her enigmas — and each fact is valuable, just in 
proportion as all its conditions are accurately ascertained, and in that 
proportion only; and in collecting these facts we should be careful not to 
allow "preconceived ideas" to become "fixed ideas." The former are 
necessary, indispensable ; we can do nothing without them ; we should 
only know how to abandon them when they are no longer right. The 
preconceived idea is always interrogative ; it addresses the question to 
nature, and calmly awaits the answer ; ceasing to question when this is 
received, and adopting the fact, whether opposed to, or in accordance with 
itself, with the same readiness (Bernard). 

That the carbon and hydrogen present exert a powerful influence on the 
results of nitrogenous decomposition cannot for a moment be doubted ; the 
power which we possess of varying the amount of urea and uric acid, and 
of producing hippuric acid, evidence this ; and, also, that in the decompo- 
sition all the elements are reduced to the nascent form. 

In conclusion we may remark, that in framing a dietary, especially in 
convalescence and in health, no difficulty will be found when these principles 
are borne in mind, and the albuminous foods most readily convertible into 
albuminose, combined with such proportions of fat, sugar, and starch as 
the condition of the assimilating organs can appropriate without subsequent 
ill effects ; and in such quantities of each that the excess, if any, be slightly 
on the nitrogenous side of the scale, will be generally the most advantageous, 
only remembering that the fat cannot" be too free from rancidity, nor the 
sugar too pure, and especially should this be remembered in the feeding of 
children ; while in all the use of gelatinous food should be but sparing. 

And while the use of fresh lean meat cannot be too strongly inculcated, 
an abundance of pure fresh air is of no less importance; for out of door 
exercise imparts an energy to the system often unknown before, and unat- 
tainable by any other means ; the more rapid the tissue-change, provided 
its replacement correspond, the less effete matter will be in the system, the 
more vigorous will be the frame, and the better able to withstand the inroads 
of disease. 

Note. — In my last article, on page 356, in the enumeration of the elements, read 
S for I, and in line fifteen from bottom omit "may undergo decomposition in the 
system, or." It will thus read: "it may give rise to decompositions," &c. &c. 
Elementary bodies cannot be decomposed. 



I860.] 



Williamson, Diphtheritis. 



99 



Art. VI. — Some Account of Diphtheritis, as it occurred on the Water- 
shed behveen the Tallahatchie and Mississippi Rivers. By Lea Z. 
Williamson, M. D., Sardis, Mississippi. 

Diphtheritis occurred in the vicinity of Sardis, Mississippi, in 1859, 
and as this affection is now attracting much attention, I will endeavour to 
present an account of the symptoms which it presented, and the treatment 
which I found most beneficial, with such other information as may tend 
to throw light on the subject. 

Symptoms. — Preliminary symptoms usually preceded the attack in adults, 
sufficiently definite to apprise an intelligent person of his danger. These 
were a dull aching of the bones, lassitude, headache, great mental depression 
and drowsiness. Children are emphatically the subjects of diphtheritis, 
and these initiatory signs were rarely observed in them. More commonly 
the child awakens in the morning, complaining of sore throat and stiffness 
of the cervical muscles ; he seems very sleepy, insists on being let alone, 
and lies with his hands folded under his head. He has some fever, little or 
no appetite, and inspection reveals redness of one or both fauces, and 
sometimes of the uvula, and tumefaction of one or both tonsils. Per- 
haps the membrane has already formed on some of these parts, or does so 
in a few hours, sometimes it does not form until the third day. Externally 
there is swelling of the submaxillary and cervical glands, and the degree 
of this is a fair and correct exponent of the internal injury. Of fifty-eight 
cases, the left side was first affected in forty-four ; in eleven, only one side 
was implicated. The exudation commences in small, irregularly whitish 
or ash-coloured patches, sometimes confined to a part of the fauces, or scat- 
tered here and there over their whole extent. If these patches coalesce, the 
whole mucous surface is concealed by the false membrane. 

Occasionally the exudation appears first on the uvula. When the sur- 
rounding surface is of a deep red, and the membrane of whitish colour, the 
fever is sthenic; when the surface is a dark livid or claret, and the membrane 
of a yellowish colour, the fever is typhoid; and when the latter condition 
succeeds the first, the prognosis is unfavourable. Between these two condi- 
tions, however, it must be remembered there are various grades, wherein 
the characteristic symptoms are more or less mingled, and modified. We 
have not observed that constitution has any determining effect as regards 
the character of the fever. In the majority of cases the fever was asthenic; 
whilst in some of the very worst cases, as regards the throat, there was 
scarcely any fever perceptible. The membrane begins to be removed soon 
after it is completed, either in strips, or by softening and mixing with the 
fluids of the mouth. They are sometimes removed, and renewed several 
times ; each time becoming thinner and whiter, and finally disappearing. 
This process lasts from five to ten days; the longer, the more unfavourable 



100 



Williamson, Diphtheritis. 



[July 



the prognosis : few recover that go to the tenth day. If it continue this 
long the fetid sanies from the nostrils, and the lancinating pain along the 
Eustachian tubes, when fluids are swallowed, indicate the extension of the 
inflammation into these passages, and there are reasonable apprehensions 
of the invasion of the larynx and trachea, which is the chief danger of the 
disease, and which will almost certainly prove fatal. 

When the disease has advanced this far, the front of the neck, the parotid 
glands, and the face are greatly swollen ; the mouth cannot be opened 
without the most excruciating pain ; the voice, although the tongue is not 
involved, is changed into a hoarse whisper ; the swallowing of fluids, even, 
is torturing. The pulse is feeble and fluttering ; the respiration is hurried 
and catching ; the indentation of the intercostal muscles from atmospheric 
pressure shows a lack of oxygen in the lungs, for the relief of which the 
diaphragm and pectoral muscles are brought into full play. The. patient is 
restless, tossing from side to side ; implores the assistance of the bystanders, 
or a release from the agonies of suffocation ; finally seeks a semi-reclining 
posture, and dies by apncea. The obstinate constipation, so often present 
in the beginning, is exchanged for diarrhoea in the later stages — the stools 
having a very offensive but not a cadaverous odour. Hseniaturia, difficult 
micturition, and suppression of urine are also common at this time. Albu- 
minuria is detected by the usual tests in the severe cases ; but cannot be 
considered a constant complication. In a few cases the serous effusion of 
the areolar tissue of the face, neck, and chest was so great as nearly to 
conceal the eye, and entirely incapacitate the patient for wearing his own 
clothes. One case had a diphtheritic membrane, formed on an excoriated 
surface of left arm, which was very tenacious, and as tardy of being removed 
by the same remedies as that of the throat ; which could not have come 
from a merely local affection. 

The system is evidently under some poisonous influence, which has pro- 
bably much to do with the fever of diphtheritis. 

The prognosis was favourable in ordinary constitutions, if early treated. 
All the severe cases that were not treated till after the second or third day, 
died. All died that had a descent of the membrane into the larynx, with 
one exception. Of 58 cases, 1 was over 40, 5 over 30, 9 past 20, 16 over 
14 years old; the other 42 had not reached the age of puberty: 40 were 
under 10, and 20 of these between the ages of 4 and 6 years ; the youngest 
was only 19 months old; no membrane formed in this case, though there 
was much inflammation and swelling. One-third more females than males 
suffered. Colour confers no immunity. 4 whites and 3 blacks died : one, 
30; two, 8; one, 6; two, 5; and one 4 years old. One died on the eigh- 
teenth, one on the tenth, one on the ninth, one on the eighth, one on the 
seventh, one on the sixth, one on the third day. 

Etiology. — Diphtheritis appeared here on a high, level water-shed, between 
the Tallahatchie and Mississippi Rivers. On each side are broad, unculti- 



I860.] 



Williamson, Diphtheritis. 



101 



vated valleys, of matchless fertility, where grows vegetation of the richest 
and rankest character, which, by the overflow going off in May and June, 
is left exposed and reeking in the sun. Superadded to this are numerous 
lakes, marshes, and sloughs, which are supposed to make this region noto- 
rious for intermittent and remittent fevers. This year (1859) the summer 
fever commenced early in June, and prevailed about as usual until August. 
The season was very dry, there having been no general rains since early in 
May. The thermometer ranged from 86° to 96° Fahr. In the last week 
of July there were copious rains, with frequent showers throughout August 
and September. With the rains came a decided change in the tempera- 
ture, the thermometer ranging from 69° to 82°. The first cases occurred 
August 5th ; a week later half a dozen families were attacked almost simul- 
taneously, without having had any communication with the first cases. It 
continued to travel in a definite direction along the eastern border of these 
table-lands, confined to very narrow limits, from which it never once devi- 
ated. Remittent bilious fever, the only disease from which the inhabitants 
usually suffer during the summer season, and which had been prevailing to 
its usual extent, seemed now merged into the prevailing epidemic ; after 
the appearance of diphtheritis not one case of fever was seen in the epidemic 
region, where scores are wont to occur. A few weeks later diphtheritis 
appeared on the western border of this ridge (diphtheritis never reached its 
centre), fronting the Mississippi bottom, differing in no respect from that 
already described. On this basis it is a fair inference that in this epidemic 
malaria and diphtheritis were in some way connected. The epidemic began 
to abate in September; there were fewer attacks, and those of a milder form. 
No rain fell after 22d September, until lYth November. The weather was 
uniform, and warm for the season ; this had a salutary effect. Patients 
were always worse during wet " spells," or when nights and mornings 
were very cool. Frequently those that had recovered, relapsed, from ex- 
posure to a cold, damp atmosphere. Diphtheritis, being a disease hereto- 
fore unheard of in this section, the people were terrified with stories of 
contagion, for which there was barely the remotest evidence. 

Diagnosis. — Diphtheritis has been confounded with scarlet fever, black 
tongue, mumps, croup, ulcerated and malignant sore throat. It wants 
the excavated surface of ulceration of the last named disease ; when, how- 
ever, the false membrane has been removed, and renewed several times, 
some excavation will be observed. 

Treatment. — I commenced this generally with purgatives, to relieve the 
constipation. Where there is much fever, a hot surface and clay-coloured 
stools, good results uniformly follow the administration of calomel in broken 
doses, followed by a saline cathartic. Most cases thus treated exhibit some 
improvement on the second or third day. Mercury is preferred as a stimu- 
lant to the secretions, and as an antiplastic to the blood. Emetics are only 
useful for expelling the false membrane from the larynx in the last stages, 



102 



Ashhurst, Nervous Action. 



[July 



thereby preventing suffocation. Iodide of potassium was given as an anti- 
plastic, also the chlorate of potash for the same end, and to correct the 
fetor. Huxham's tine, bark and mur. tine, iron were beneficial in the low 
and lingering cases. Chlorinated soda, a drachm to three ounces of water, 
is an excellent gargle. The application of nitrate of silver, solid or in 
solution (a drachm to the ounce), to the inflamed surface, once or twice a 
day, was a prominent and indispensable part of the treatment in the severe 
cases. Externally, the most active counter-irritants are the best applica- 
tions. The merits of flies, mustard poultices, stimulating lotions, and 
rubefacient liniments were thoroughly tested — the same arguments urged 
against blistering in other throat affections apply in this. Mustard vindi- 
cates itself from these, and is decidedly a superior application ; and when 
added to Indian meal or wheat bran poultice, can be tempered to the 
patient's tolerance. It alleviates the internal pain, and controls to some 
extent the diphtheritic exudation. 

Sequelae. — In several cases serious secondary affections came on after the 
throat had recovered, characterized by universal paleness of the skin, lips, 
tongue, and mucous surface, and extreme whiteness of the conjunctiva. 
The muscles are soft and flabby; the patient is feeble; has a sort of random, 
shuffling gait; cannot grasp and retain bodies by the hand. There is 
great mental depression, and disposition to sleep ; constant constipation, 
feeble appetite, and digestion. Neuralgic pains of neck, shoulders, and 
body are common. In one case sight was so much impaired that large 
print could not be read, and the voice was nearly destroyed. The soft 
palate and uvula dangled in the pharynx like a dead curtain. The larynx 
of this person had been severely affected. All of these cases recovered under 
rational treatment. 



Art. VII. — On Nervous Action. By John Ashhurst, Jr., M. D., . 
of Philadelphia. 

Nervous action is of two kinds — direct and reflex. Until within a com- 
paratively recent time the nerves were supposed to receive excitation only 
from the mind; while the tendency now is to neglect the mind entirely, and 
attribute all nervous manifestations to reflexions of external impressions. 

Two questions of considerable interest here present themselves, viz : 1. 
How many of our actions are reflex ? 2. What constitutes nervous action ? 
The first of these inquiries may be, to a certain degree, answered by experi- 
ment and observation ; the second is almost entirely speculative. 

The phenomena of sensibility may be in a great degree reflex in their 
nature, and many intellectual operations may be placed in the same cate- 
gory ; but the same source of knowledge which informs us of our own 



I860.] 



Ashhurst, Nervous Action. 



103 



existence, as certainly teaches the power of volition. Every man knows 
he can will a thing, and no reasoning can convince him of the contrary. 

Obviously an impression upon the periphery of the body, being trans- 
mitted to the nerve centres, may excite sensation, perception, an intellectual 
act, and perhaps what appears an exercise of the will, producing a secondary 
emotion, or even an apparently voluntary action ; and this is all, in a certain 
sense, a reflex phenomenon. Given a nervous system and an excitant and 
the phenomena are produced. But the will can originate actions, and can 
modify or even arrest those which are excited from without. I do not refer 
to such actions as vomiting, or those which are obviously reflex, but to 
such as would generally be called voluntary. For instance, a person earn- 
estly engaged in reading or writing shall be annoyed by an insect, and shall 
take measures to rid himself of it without consciousness of his own actions. 
The sensation of irritation is produced in his nerve centre ; perception of 
the source, intellection of the means of its removal, and volition to put 
these means in use follow each other so rapidly as to appear coexistent. 
And yet is it not a reflex act? 

Fortunately these nice questions, which savor more of metaphysics than 
of medicine, involve little that is of practical importance. Reflex action, 
as it is traced in various functions of the body in their physiological and 
pathological states, is of comparatively easy comprehension. For the 
accomplishment of a reflex action there are needed a nerve centre and 
afferent and efferent nerve fibres. An impression being made upon the 
peripheral surface, to which an excitor nerve is distributed, some modifica- 
tion, into the nature of which I shall inquire hereafter, is there produced, 
transmitted to the nerve centre to which the sensory nerve fibres tend, and 
thence by reflexion produces certain results in whatever parts are supplied 
with motor influence by the nerve fibres thence proceeding. 

Take as an illustration the act of vomiting. It is effected by a peculiar 
combination of the actions of the respiratory muscles, with probably some 
assistance from the stomach and bowels. It may be produced in various 
ways : 1. An irritating emetic, as mustard, by an impression on the centri- 
petal branches of the pneumogastric, causes a modification in the condition 
of the respiratory nerve centre, "probably," says Dr. Wood, "in the me- 
dulla oblongata and the neighbouring parts of theencephalon here reflexion 
is brought about, and by the motor fibres thence proceeding such disposi- 
tions of the pharynx, larynx, diaphragm, abdominal muscles, &c, are 
induced as give rise to the phenomena of vomiting. 2. Substances in any 
way introduced into the system, by entering the blood and directly coming 
in contact with the nerve centre, may produce the same result ; in this case, 
so far as concerns the nervous system, more properly by radiation than 
reflexion. 3. Tickling the fauces by reflex action produces vomiting. 4. 
Disease of the brain, and even certain ideas and emotions, are sufficient to 
produce the same result. 



104 



Ash hurst, Nervous Action. 



It is customary to say that reflex actions are produced independently of 
volition, and in some cases even of consciousness ; and it is obvious that 
such is the case in respiration, deglutition, defecation, vomiting, &c, which 
are all reflex actions. But no strict line of definition can be drawn between 
those acts which are and those which are not of a reflex nature ; Kirkes 
includes the so-called involuntary shrinking of a part when a blow is aimed 
at it among reflex actions ; others call the acts of walking, &c, reflex, and 
in some cases they certainly appear so. I have in walking along a crowded 
street been met by an intimate friend, who, without recognizing me or being 
conscious of my presence, has stepped to one side to allow me to pass ; thus 
adapting means to avoid a collision without consciousness apparently, and, 
as it were, involuntarily; yet this could hardly be called a reflex action, in 
the ordinary sense of the term. No limit, it would appear, can therefore 
be with justice assigned as distinguishing reflex from other actions. 

Three kinds of nervous reflexion are admitted by Dr. Carpenter, viz : 1, 
excito-motor; 2, sensori-motor; and 3, emotional and ideo-motor reflexion. 
The first finds its centre in the spinal cord, and its phenomena are chiefly 
manifested when the communication with the parts nearer the brain is inter- 
rupted by division or disease, though when the mind is closely engaged 
upon any subject, or during sleep, such excito-motor reflex acts may be 
manifested. 

Sensori-motor reflexion has its nerve centre in the so-called sensory gan- 
glia, including the medulla oblongata, corpora striata, thalami optici, &c. 
Under this division would be found the instance referred to immediately 
above, sensation producing the ordinary results of an intellectual act without 
the intervention of such intellectual operation. So with all the secondarily 
automatic acts of Dr. Carpenter. Here it will be perceived the same result 
may be produced with or without the co-operation of the intellect. But 
actions of a still more complex nature present many claims to be included 
as phenomena of reflexion. The intellect itself may be involved by the 
automatic action of the cerebrum. Illustrations of this are found in dream- 
ing and somnambulism. Many instances are authenticated in which, while 
dreaming, external circumstances have modified the course of the dream, 
and caused actions such as would have ensued had consciousness and voli- 
tion been present. A somewhat similar case is that so often quoted of the 
criminal who died of fright by the simple flowing of tepid water over his 
limb, accompanied by the suitable remarks of the attendants ; the syncope 
was as complete as if resulting from actual loss of blood. A similar 
instance is recorded by Professor Bennett : "A butcher was brought into 
the shop of Mr. MacFarlan, the druggist, from the market place opposite, 
labouring under a terrible accident. The man on trying to hook up a heavy 
piece of meat above his head slipped, and the sharp hook penetrated his 
arm so that he himself was suspended. On being examined he was pale, 
almost pulseless, and expressed himself as suffering acute agony. The arm 



I860.] 



Ashhurst, Nervous Action. 



105 



could not be moved without causing excessive pain, and in cutting off the 
sleeve he frequently cried out ; yet when the arm was exposed it was found 
to be quite uninjured, the hook having only traversed the sleeve of his 
coat," Here we have reflex motion, reflex sensibility, intellectual activity, 
and what might almost be called reflex volition. 

Many familiar occurrences come under the same head ; the suggestion of 
a caterpillar to a sensitive person will cause him to feel the inroads of 
several of those creatures as distinctly as if they were actually present, 

So the automatic expression of an idea which is present in the mind, by 
a person's own free will or by the suggestion of another, will give rise to 
actions which can hardly be believed to be, but which are undoubtedly 
involuntary. Such are the phenomena of the "divining rod," which can 
be explained by the " expectant attention" of Dr. Carpenter much more 
rationally than by supposing a new "odylic" force in nature. Such, too, 
are the phenomena of table-turning, spiritualism, and mesmerism, all of 
which are the results of "unconscious cerebration," causing acts and words 
which impose not only on the spectator, but frequently upon the medium 
himself. 

Seeing, therefore, the great number of apparently spontaneous and volun- 
tary acts which are produced really without either consciousness or volition, 
it is not surprising that some should have jumped by analogy to the con- 
clusion that man was a mere machine, acted upon by and responding to 
external influences, without power of resistance, and, therefore, without 
accountability for the results. And such appears to be the case, to a cer- 
tain extent, with savages and infants. But let us beware of that "falling 
heap" argument, impossible to refute, and yet obviously fallacious. At 
what age or with what degree of education and refinement free agency, and, 
therefore, moral responsibility begin, it is impossible to say ; but conscious- 
ness, the greatest, because the earliest instructor of human nature, declares 
to each one of us, in such a manner as is incontrovertible, that to be what 
we are implies necessarily to be capable of volition. 

Keflex action is effective not only in these animal functions of the 
economy, but its operation may be traced in the organic processes also ; 
for instance, in nutrition and secretion. The influence of reflex action on 
the calibre of the bloodvessels, and the consequent degree of animal heat, 
was shown by some very interesting experiments of MM. Tholozan and 
Brown-Sequard, made some years since, and republished in the latter's 
journal for July, 1858. The result referred to is expressed in these words: 
"Que Pabaissement de la temperature d'une main peut amener un abaisse- 
ment considerable de la temperature de l'autre main, sans que la tempera- 
ture generale du corps diminue sensiblement. " By the process of exclusion 
they show that this diminution of temperature must be due to the smaller 
calibre of the vessels, and that this is evidently caused by the reflex influence 
of the spinal column. In this connection the experiments of Bernard may 
be referred to, showing the influence of the cerebro-spinal system in increas- 



106 



Ashhtjrst, Nervous Action. 



LJuly 



ing the vascularity of glands, causing the secretion to be increased, and 
the venous blood coming from the gland to assume an arterial hue (couleur 
rutilante); and even to flow by jets (un jet saccade, isochrone au pouls), 
while precisely contrary results were shown to be due to the sympathetic 
system. — Broivn-Sequard' 's Journal, vol. i. pp. 240, 241. 

It is, I believe, in the application of these results to the subject of 
inflammation that we are to look for the perfection of our theories of that 
process. 

Not only is reflex action manifested in the normal condition of the body, 
but in many pathological states its phenomena are shown in what have 
been called the sympathies (the first correct views of which were, I believe, 
promulgated by Prof. Samuel Jackson, of the University of Pennsylvania, in 
his work on the " Principles of Medicine," published in 1832). This term 
"sympathy" has often been applied in a very vague manner, being used as 
a last resort when other modes of explanation have failed. What consti- 
tute in a diseased state sympathies, in health are hardly recognized, but, 
nevertheless, exist ; synergy being in a normal what sympathy is in an 
abnormal condition. The stomach is rich in sympathies with other parts 
of the body, while the ever -varying sympathetic irritations dependent on 
uterine affections are almost proverbial. 

In a therapeutical point of view reflex action is interesting, as indicating 
the modus operandi of certain medicines. Thus, it is believed by Dr. Car- 
penter that ergot, cantharides, aloes, and some others produce their several 
effects by stimulating the spinal cord to unusual sensitiveness to accustomed 
influences. Conversely opium, by obtunding the sensorium, prevents the 
action of the most powerful emetics. 

The higher kinds of reflex action (the sensori-motor and ideo-motor of 
Dr. Carpenter) are brought out especially in certain abnormal states which 
may arise spontaneously, or by artificial induction. Of the former are 
various forms of delirium and mania ; of the latter the states brought on 
by narcotic medicines, especially opium and the cannabis indica. With 
regard to the effects of opium we have reliable information in the well- 
known work of Dequincey; the "hasheesh eater" unfortunately excites 
disbelief by his marvellous anecdotes — disbelief which was not diminished 
by the long-time anonymous character of his publication. 

It will be remembered that a second question was referred to as of interest 
in this connection, to wit: "In what way is nervous influence transmitted?" 
It was said that a certain modification in the condition of a nerve or nerve 
centre was brought about, which being transmitted produced such and such 
results. In what does this modification consist? In other words, what 
is nerve force? A favourite illustration, but which will hardly serve as an 
explanation, is that of the magnetic telegraph, with its wires and stations; 
and the compliment has been returned by our great American humorist, 
who has called the Atlantic telegraph cable the "great par vagum" of the 
world. Electricity, however, is but a name, conveying no very definite idea 



I860.] 



Ashhurst, Nervous Action. 



107 



as to the true nature of the force. It is probably (undoubtedly to my own 
mind), as are the other "physical forces," a form of motion, consisting of 
vibrations or, more properly, undulations, i. e. propagated vibrations. 

Whether the hypothetical, all-pervading substance " ether" has a real 
existence, or whether the undulations of light, heat, sound, &c, are propa- 
gated by the various substances which surround us, I will not stop to 
inquire. I am inclined to think that the phenomena of optics could be 
explained without supposing such a fluid to exist. Be this as it may, I 
believe that in whatever manner the undulations of light, and sound, and 
heat take place (each having some substances specially adapted for taking 
on its peculiar vibrations), so do the undulations of electricity, and so do 
the undulations of nerve force take place. 

It may not be uninteresting to trace the history of this hypothesis, for it 
can hardly as yet be called a theory. The idea that nerve force consisted 
in undulations was hinted at as possible by Le Gros Clark, in the Ency- 
clopedia 3Ietropolitana ; and such an idea, though not fully developed, 
appears to have been entertained by Prof. Samuel Jackson, of the Uni- 
versity of Pennsylvania, as early as 1837. In a published introductory 
lecture of 1851, he says: "Nervous force is correlative with heat and 
electricity, though not identical ;" and the identity of the physical forces 
has been taught by him for over twenty years. 

As has been before observed, the nature of the case prevents the demon- 
stration of any hypothesis on this subject, as either true or certainly false; 
but some analogies may be indicated, and some reasons adduced why such 
a view has been adopted. 

That sound was the result of undulations seems never to have been 
doubted, so manifestly coincident are its impulses with the seen vibrations 
of a sonorous body; and hence it is in the science of acoustics that those 
beautiful laws of undulation have been especially developed. Light is now 
generally conceded to arise from the same source. Heat is also believed to 
be produced by undulations ; and these are all correlative and interchange- 
able. 

The vibrations of sound are the same in nature, but more slow than 
those of heat ; and it is probable that could vibrations be made to succeed 
each other with sufficient rapidity, light also might thus be artificially pro- 
duced. Chemical action again probably has its source in still more rapid 
vibrations. 

Now it seems to me more rational to suppose that the undulations of 
light are taken on by the optic nerve, or by the ether or phosgene (if its 
existence be supposed) therein contained, and thus transmitted to the gan- 
glia belonging to that special sense ; and that the undulations of sound 
are taken on by the auditory nerve, or the ether therein contained, and 
transmitted as before ; this, I say, seems to me to be more rational than 
to suppose some mysterious nervous fluid, or something still more myste- 
rious, without name, to be set in motion, and thus bring about the subse- 



108 



Huber, Oblique Fracture of the Femur. 



[July 



quent results. The sense of smell I imagine to be explicable in the same 
way. In man this sense is in an almost rudimental condition, and conse- 
quently not often excited, but by actual contact with the Schneiderian 
membrane, of odorous particles or fumes. Yet a piece of musk shall be 
exposed for years without losing appreciably in weight, and I doubt not 
that the function of olfaction may be excited by undulations alone. So 
with the other special senses, and by analogy with what is called common 
sensibility, though this may be regarded as merely a modification of the 
sense of touch. 

A further evidence for this hypothesis is that whatever excites a nerve 
of special sense produces in it its special phenomena ; thus, irritation of 
the optic nerve causes only the sensation of light, while the auditory nerve 
can take on only the undulations of sound. 

If then, as far as we can observe nervous action in its relation with the 
external world, undulation appears to be the modus agendi, the inference is 
allowable that all nervous action is referable to the same process. And it 
would appear that without regard to the mind (which is sui generis, and 
as to its nature entirely beyond our ken) nerve force presents analogies 
which entitle it to a place among the physical forces. It appears to be 
correlative with them, i. e. can be " mediately or immediately" transformed 
into them, or produced from them. The sensations of light, heat, sound, 
&c, may originate subjectively. In the contraction of muscular fibre both 
heat and sound are produced, motion being intermediate. Electricity again 
is correlative with taste and smell, sight, hearing, and general sensibility. 
The increased heat of fever is probably due in a great degree to the morbid 
nervous action, while here is also one source of the maintenance of the 
animal temperature. 

The "physical forces" arise from without; nerve force finds an excitant 
also in the inner world — the will and the soul. 



Art. Yin. — Case of Oblique Fracture of the Femur treoJ.ed by the 
use of Adhesive Plaster, as a means of producing Extension and 
Counter-Extension. By J. F. Huber, M. D., Lancaster, Pa. 

On Monday, January 9, 1860, J. E., aged fifty-nine years, was wheeling 
his scissor-sharpening apparatus on the icy pavement, when he fell ; the 
shaft of his wheelbarrow struck him with great force on his right thigh. 
He was carried to his home, a distance of four squares. One hour after 
the accident had occurred I saw him, and discovered an oblique fracture of 
the femur about the junction of the middle with the inferior third, shorten- 
ing the limb nearly one inch and a half. 

Periostitis of a syphilitic character existed in the leg, and his body was 
covered with secondary syphilitic eruptions. I consented very reluctantly 



I860.] 



Huber, Oblique Fracture of the Femur. 



109 



to take charge of the case, for I apprehended much difficulty, if not com- 
plete failure, in securing firm and permanent union of the fractured bone, in 
consequence of his system being thoroughly saturated with syphilis, and 
debilitated greatly from his former habits of dissipation, which fortunately 
had been relinquished about one year ago. 

I adjusted the apparatus recommended and described in a very elaborate 
manner by Dr. David Gilbert, in the April number of the American Journal 
of the Medical Sciences, for 1859. For want of adhesive plaster of suffi- 
cient length, the ordinary perineal band was temporarily applied. The 
patient was somewhat restless the succeeding day, and required some mor- 
phia to produce rest. The third day he was restless, had fever, and com- 
plained much of an unpleasant sensation where the perineal band rested. 
This band was removed, and the adhesive plaster applied in its stead. The 
irritation subsided immediately, he rested well the following night, and 
continued without pain or uneasiness during the entire period of treatment. 

In order to improve the condition of his system and favour a desirable 
termination, drachm doses of the ferrated tincture of bark were administered 
four times a day for several weeks, with a nourishing diet. On the tenth 
day the bandages and splints were removed, in order to institute a careful 
inquiry into the condition of the fracture, after which they were adjusted 
as before. This was repeated again on the twenty-first day. 

On the 20th of February, precisely six weeks after the occurrence of the 
accident, they were permanently removed, the bone was found firmly united, 
and the limb its original length. Locomotion was assisted for awhile with 
crutches ; however these were soon dispensed with, the function of the 
extremity being fully restored. 

It was not necessary to replace the adhesive bands ; the ones first applied 
adhered firmly to the skin during the whole period of treatment. Care 
must be observed in the application of the adhesive strips ; they should be 
uniformly heated by placing the linen back against some hot surface, until 
the adhesive material on the opposite side is thoroughly softened, when it 
should be applied very smoothly to the skin, so as to exclude air entirely. 

Adhesive plaster, properly applied, forms the most admirable means of 
producing extension and counter-extension. It is far superior to any other 
method with which I am familiar, for the following reasons, viz : — 

1. The excruciating pain so often produced at the heel, and in the peri- 
neum, when the gaiter and stuffed perineal band are applied, the consequent 
restlessness of the patient, with his earnest importunities to the surgeon 
for relief, are entirely obviated when adhesive plaster is properly applied as 
the means of producing extension and counter-extension. 

2. The surgeon has perfect control of the extension and counter-exten- 
sion, without being annoyed with pitiable requests and affecting entreaties 
from the patient and his friends, to relax the limb in order to obtain relief 
from his sufferings. He has power to increase or relax the extension at 



110 Lea, Poisonous Effects of Arsenical Preparations. [July 



any time, or to any degree lie may desire, and thus secure the original 
length of the extremity after a firm union of the fragments has been effected. 
This was considered impossible in oblique fractures when the ordinary 
methods of treatment were practised. 

3. The perfect quietude of the fragments at the seat of fracture, the 
absence of irritation and irritative fever, the great comfort enjoyed by the 
patient, consequently his non-interference with the retentive apparatus, will 
secure union of the fractured bone in at least twenty -live per cent, less time 
than by the usual methods of treatment. 

4. The adhesive plaster counter-extending bands require no trouble by 
way of readjustment every day or two, which is so necessary in the old 
method. 

5. If the adhesive plaster be carefully applied, the bandages and splints 
readjusted when they become relaxed by the diminution of the swelling of 
the limb, and osseous union is about taking place, the patient will require 
but little attention afterwards. In consequence of the above facts, this 
method is best suited to country and all private practice, especially when 
the attending surgeon is not constantly at hand. 



Art. IX. — On the Poisonous Effects resulting from the Employment of 
Arsenical Preparations in the Arts. By M. Carey Lea, Esq. 

Much attention has been attracted of late years in Europe to the increas- 
ing use of arsenical pigments in matters connected with domestic economy. 
Formerly, when Scheele's green and orpiment were the chief colouring sub- 
stances into the composition of which arsenic entered, their comparatively 
limited use rendered their poisonous character of less importance ; but since 
the discovery of the substance sold under the name of Schweinfurt green, 
Swedish green, Mitis green, &c, the case is different. This substance, the 
aceto-arsenite of copper, obtained by boiling together green verdigris and 
white arsenic, possesses the finest colour of all known green pigments : this 
fact, together with its easy production from inexpensive materials, has 
caused a great extension of its use, and it is time that the impropriety of 
employing so deleterious a substance should be brought home to those who 
use it in their manufactures. 

The immense extension which its employment has received, even in this 
country, may be judged of by the following facts : — 

The author had recently two rooms papered with different green papers, 
obtained from different manufacturers. On examination it proved that the 
green colouring matter in both papers was arsenical. The border was then 
examined with a like result. The author procured three different specimens 



I860.] Lea, Poisonous Effects of Arsenical Preparations. Ill 



of green material prepared for window shades ; all three were found to be 
heavily charged with arsenic, so much so that from about two square inches 
of one of them no less than six grains of arsenite of silver were prepared, 
by precipitating the arsenious acid with nitrate of silver. As these mate- 
rials varied not only in intensity, but in colour also, the arsenical pigment 
is no doubt often mixed with other colouring matters — a fact to be borne 
in mind in making examinations to detect its presence. 

Not only the above-mentioned manufactures, but many others, are co- 
loured with the same substance. It is largely used in dyeing carpets. The 
large pasteboard boxes, so much used in stores for containing fine fabrics, 
and those employed for keeping documents and papers, are almost always 
covered with paper coloured green by arsenic. So with the green shades 
for gas lights, and when the eye becomes acquainted with the peculiar shade 
of Schweinfurt green, it is surprising in how many things it is detected. 

When these considerations are represented to. those who employ this 
pigment in their manufactures, they are met by a denial of its bad effects, 
and by an unsupported assertion that no evil results from its employment. 
The answer to this is, that no doubt much of the evil resulting from arsenic 
is attributed to other causes. The quantity taken into the system in a 
short period is but small ; but the gradually cumulative effect of constant 
small inhalations of arsenic over a space perhaps of years, must be highly 
injurious. Facts are not wanting, however, but, on the contrary, are 
present in abundance, to prove direct evil effects clearly and immediately 
resulting from this cause. The author was informed by a journeymen 
paper-hanger that he never put up certain shades of green paper without 
having his nose, and often his whole face, swelled. In a recent medical 
journal a case is mentioned where several children fell into a decline, and 
exhibited such strong symptoms of arsenical poisoning that the physician 
directed them to be removed to another room, where they speedily recovered. 
On examination, the paper of the room originally occupied by them was 
found to contain arsenic. In a recent number of the London Chemical 
News a case is related by the sufferer himself, who, moreover, states he was 
informed by paper-hangers that no one could have anything to do with that 
description of green paper without irritation of the mucous membranes of 
the throat and fauces. Finally, the author subjoins a few lines translated 
from Dr. Otto, than whom there can be no higher authority on the subject 
of poisoning by arsenic. 

"Schweinfurt green is frequently used for colouring carpets and window 
shades; but is, on account of its poisonous, character, a very dangerous colour. 
Apart from the poisonous dust which window shades especially produce, the 
pigment in moist situations disengages deadly arseniuretted hydrogen. Swedish 
green, Neuwicd green, Mitis green, and many other beautiful green pigments, 
are all Schweinfurt green mixed with colourless substances. 

"The use of all these arsenical colouring matters is forbidden in Prussia' by 
law." — Graham-Otto, third edition, vol. iii. p. 477. 

Amongst the many reactions which afford decisive proofs of the presence 



112 Lea, Poisonous Effects of Arsenical Preparations. [July 

of arsenic, the following will be found very convenient for detecting it in 
the fabrics in common use in the household, such as carpets, wall papers, 
window shades, curtains, &c. : — 

The suspected substance is immersed in liquid ammonia, and allowed to 
remain in contact with it for some hours. The resulting liquid is then to 
be filtered or decanted, and treated with pure nitric acid until it is rendered 
perfectly neutral. A very slight alkaline reaction is not important ; but 
the liquid should not be acid. Any trace of arsenic is then made evident 
by the addition of nitrate of silver, which causes an immediate yellow pre- 
cipitate. 

The only substance which affords a precipitate liable to be mistaken for 
that of arsenious acid is phosphoric acid, which also with nitrate of silver 
gives a lemon yellow precipitate. Phosphoric acid is, however, not likely 
to be present in any of the above-mentioned substances ; but when a yellow 
precipitate is obtained it is easy to decide whether it consists of phosphate 
or arsenite of silver. 

For this purpose a tube of glass, which should be free from lead, having 
about a quarter of an inch in internal diameter, is to be drawn out so that 
its extremity, for about an inch in length, may have an internal diameter 
at about one-fifteenth of an inch. The yellow precipitate having been 
washed and dried, a portion of it, about as large as a large pin's head, is 
placed at the bottom (previously closed in the lamp), and over it a fragment 
of charcoal. The charcoal must not be in powder, otherwise it is liable to 
be carried into the cool part of the tube, and thus mask the result ; it must 
also be thoroughly burnt. The author has found that by cutting fragments 
of the stems of lucifer matches about an inch in length, placing them in a 
test tube and applying heat until no more gases are disengaged, a pure, 
soft, and flexible charcoal is obtained, of exactly the shape requisite for the 
use intended. 

The charcoal being adjusted, the narrow part of the tube is placed on 
the flame of a spirit lamp, so that the charcoal, and not the substance, shall 
be heated. When the charcoal is red hot, the tube is inclined from its 
previous horizontal position, so as to bring the point of the tube where 
the substance lies, into the flame, keeping still the charcoal in it also. The 
silver salt is immediately decomposed. If it contain arsenious acid, the 
latter is immediately reduced by the charcoal, and forms a grayish-black 
ring in the cool part of the tube. Very good figures, illustrating the ope- 
ration, will be found in Graham-Otto, Lehrbuch, vol. iii. p. 508. 

The use of arsenic is now obtaining so dangerous an extension in manu- 
factures, that the public have a right to ask for protection by legislative 
enactment, which should without delay be applied to put a stop to this 
reckless traffic. 



I860.] 



Hord, Compound Fracture of Bones of Tarsus. 



113 



Art. X. — Case of Compound Fracture of the Bones of the Tarsus, 
implicating the Ankle-Joint, with perfect Recovery. By Wm. T. Hord, 
M. D., Passed Assistant Surgeon U. S. Navy. 

Frederick Langdon, seaman, aged 24, born in England, was admitted 
on the evening of September 1, 1859, with compound fracture of the astra- 
galus, os calcis, and cuboid bones of left foot, subluxation of right wrist, 
and other minor injuries. 

He had fallen from the main rigging to the spardeck, a distance of fifty- 
seven feet, struck with the hollow of his left foot upon the end of a belaying 
pin, in the rail about the mast, making a very large lacerated wound in the 
soft parts, and shattering the rounded head of the anterior extremity of the 
astragalus, the os calcis, and cuboid. The finger could easily be passed 
into the ankle-joint, through the lacerated wound in the sole of the foot. 
The hemorrhage was very profuse, and arterial in its character ; the wound 
of the soft parts was very extensive, entirely severing the outer half of the 
foot. The contusion was very great, and the integument was torn up in 
every direction from the wound, to the extent of two or three inches. 
Several small pieces of bone were picked up about the deck. The lacera- 
tion of soft parts was so great, that the hemorrhage was not so large as 
was feared from the extent of the wound, and the vessels involved. 

The man being young, and in vigorous health, it was thought best to 
attempt to save the foot, notwithstanding the severity of the injury; there 
was no great displacement of the bones ; a few loose spiculse were removed. 
There was no hemorrhage from any large artery requiring a ligature. 
Wet lint was applied to the wound ; the foot bandaged, elevated, and close 
watch kept to see if the bleeding was checked. He took morph. sulph. 
gr. ss twice. 

September 2. Passed a tolerably comfortable night. The hemorrhage 
has ceased ; the foot is somewhat swollen and painful. There is some 
febrile action. Keep foot elevated, and as swelling is not great, let dress- 
ings remain for fear of recurrence of hemorrhage. Diet farinaceous ; 
opiates, if necessary. 

3d. Removed dressings this morning for the first time since reception of 
injury ; there is a good deal of tumefaction of foot and ankle ; the wound 
shows that the line of demarcation has taken place between the dead and 
living parts. Pulse 92 ; skin cool ; tongue clean ; complains of but little 
pain in foot ; slept some last night. No discharge from bowels for three 
days. Take sulph. magnesia ^ss, and repeat this evening, if necessary; 
keep foot elevated, and continue applications of cold water ; diet light ; 
opiates, if necessary. 

4th. The foot is very much swollen; edges of wound puffed out ; not 
very painful ; no fever. Sulph. magnesia acted well. Anodynes, p. r. n. 

bth. Foot and ankle very much swollen to-day. Some discharge of pus 
from wound. Cold water still feels very comfortable ; continue it ; keep 
foot elevated. Low diet. 

&th. Doing well ; the line of demarcation between dead and living parts 
better defined ; no fever ; less swelling in ankle-joint ; swelling in foot very 
great ; bowels regular. Continue treatment. 

*lth. Doing well ; no fever ; foot very much swollen ; slough disposed to 
separate. Discontinue applications of cold water, and apply poultice of 
flaxseed meal. 

8th. Foot looks very well this morning ; the dead parts are separating, 
No. LXXIX.— July 1860. 8 



114 



Williams, Dislocation of the Astragalus. 



[July 



and the edges of the wound look healthy, though still much swollen. Con- 
tinue poultice. 

9th. Sloughs separating. Apply sol. nit. plumb, to correct fetor. Gene- 
rous diet. 

11th. Improving, swelling subsiding ; suppuration very profuse ; wound 
granulating. Continue poultice ; and nit. plumb, sol. (gr. x to aqua gj) 
to correct fetor. Generous diet. 

14th. All sloughs appear to be separating from the superficial parts of 
wound. Discharge still very profuse. 

15th. Foot looks very well ; is granulating finely. Apply roller and 
simple dressing to foot ; poultice discontinued. 

From this time there was continued improvement; the swelling began 
to subside ; the displaced outer anterior part of the foot to return to the 
proper position. Passive motion at the ankle-joint every day or two. 

He was discharged to duty November 28, 1859, with a perfect use of 
foot and ankle, and only a very deep cicatrix at the side of wound. 

It is somewhat remarkable that, notwithstanding the severity of the 
injury, not a single bad symptom manifested itself. 

Such extensive injury of the foot and ankle is generally considered to 
render amputation unavoidable, either primarily or secondarily ; but in this 
instance of very extensive injury the recovery is perfect. 

At the date of this report the man is and has been doing duty: he has 
no pain in foot or ankle, and has perfect motion in the joint. 

U. S. Sloop of War Lancaster, Bay of Panama, Feb. 18, 1860. 



Art. XI. — Case of Dislocation of the Astragalus, occurring on board 
U. S. Sloop of War Jamestown. By T. L. Williams, M. D., Surgeon. 

W. M., landsman, oet. 24, native of Maryland, admitted to the sick list 
November 29, 1859. While "loosing sails" was knocked from the main- 
yard and fell to the deck, a distance of forty-two feet, striking the main 
rigging in his descent. Upon examination, immediately after the accident, 
it was found he had received a contusion of the right hip and a dislocation of 
the right astragalus forwards. The foot was turned inwards, the outer edge 
of the sole looking downwards. The head of the astragalus was prominent, 
resting on the upper surface of the scaphoid. No fracture of tibia or fibula. 

Reduction attempted at once, failed, until the patient was etherized; when 
the bone was replaced by pressing it backwards, at the same time extending 
and straightening the foot. Limb placed upon a double inclined plane, and 
the foot loosely fastened to the footboard ; lead water to the joint and foot. 

November 30. Foot and leg much swollen ; extravasation of blood over 
external malleolus. 

December 4. Swelling subsiding, and Scultetus's bandage and rest on 
inclined plane. 

12th. Swelling has nearly disappeared; apply roller, and remove limb 
from inclined plane. 

lQth. There is still effusion around the joint; apply pasteboard splints 
and roller; motion of the joint perfect. 

January 2. Ordered passive motion of joint ; continued roller. 

5th. To move about once or twice daily, with crutch and stick. 

February 1. Continued to improve; has good use of the joint; there 
is still thickening and tumefaction over external malleolus. Sent to the 
United States. 



I860.] 



115 



TEANSACTIONS OF SOCIETIES. 



Art. XII.-— Summary of the Proceedings of the Pathological Society 

of Philadelphia. 

1860. Feb. 2-2. Dr. Packard presented specimens of fibrous tumours 
of the uterus and hypertrophy of the heart, accompanied by disease of the 
mitral valve and aorta. The tumours were of very large size, and grew 
from the fundus of the uterus ; the neck was healthy. The patient had 
not suffered any material inconvenience from the morbid growth. 

Perforation of a Pulmonary Valve. — Dr. Hall, in bringing forward 
this specimen, said, that although almost destitute of history, he thought it 
would interest the society, as it was the first of the kind that has been 
submitted to its notice, and as it was of very unusual occurrence. The 
whole subject seems, indeed, to be still in an unsettled state ; many practi- 
cally leaving out disease of the right side of the heart in an estimate of 
cardiac diagnosis. A careful inspection of the records of pathology for the 
past few years will, however, prove that morbid conditions of the pulmo- 
nary artery and its valves are of more frequent occurrence than has been 
stated by many standard writers on diseases of the heart. 1 

The specimen upon the table was removed from a man, aged forty-two, 
who died in the summer of 1857, in the Pennsylvania Hospital, during the 
service of Dr. Gerhard. He had been sick for eight months. On admission 
he did not appear to be very ill ; he had shortness of breath, and there 
were large bronchial rales over the posterior part of the chest. Over the 
base of the heart was heard a double sawing sound, completely obscuring 
the normal sounds. 

At an examination after death the aortic valves were found to be healthy. 
But in one of the pulmonary valves was detected a perforation about the 
size of a large goose quill ; at the edge of this was a small, single, pedicu- 
lated vegetation. The mitral valves were thickened and opaque, with a 
fibroid deposit in one of the curtains. 

Dilatation, aneurism, contraction of the pulmonary artery, are not as 
rare as affections of its valves. Louis 3 has recorded quite a number of 
the former conditions. The alteration of the valves may embrace every 
degree of change, from mere fibroid thickening up to their entire destruc- 

1 Skoda, Auscultation and Percussion, Philadelphia, 1854, p. 281 ; Hope on the- 
Heart, Philadelphia, 1842 ; Crisp on the Arteries, London, 1847. 

2 Recherches Anatomico-Pathologiques sur la Pericardite, Paris, 1826, 



116 



Proceedings or the 



[July 



tion. 1 Single perforation, as contrasted with a cribriform state of the 
valves, appears to be a less frequent lesion than any of the others above 
mentioned. At the autopsy of Sir Astley Cooper, made by Mr. Hilton, 
there was found "through one of the pulmonary valves, near its angle of 
union with an adjoining valve, a perforation nearly the size of a small 
goose quill." There were also affections of the valves of the left side. It 
is not mentioned whether there was hypertrophy of either ventricle. 

In the recent work on pathological anatomy, by Dr. Wilks, 2 it is stated 
"that you may every day meet with a perforated or fenestrated condition 
of the aortic and pulmonary sigmoids, above the crescentic line where they 
are apposed. The perforation can, therefore, produce no ill effect. These 
small holes have often been looked upon as a result of atrophy; but there 
is little proof of this. I have seen them in young people, and I have 
always regarded them as congenital ; for on some of the lower animals the 
sigmoid valves are attached to the artery by their tendinous cords (which 
are produced here by the perforated condition), in the same way as the 
auriculo-ventricular. ' ' 

It is possible that these defects may now and then be congenital ; but 
there is no evidence to show that they are so, and there are the strongest 
reasons for believing that in the great majority of cases they occur at 
periods subsequent to birth. 

Generally these alterations of the pulmonary valves appear to arise from 
the extension of endocarditis of the right ventricle. Guy's Hospital Mu- 
seum 1413 5 5 furnishes an example of their entire destruction from this 
cause. 3 

These perforations of the valves, regarded by Wilks as congenital, are 
attributed to interstitial absorption by Kingston. 4 Of thirty cases of dis- 
eased valves he found the mitral valve cribriform in one, in two the tricus- 
pid, and in one both the aortic and pulmonary valves were so. 

While upon this subject I cannot refrain from quoting two cases, the 
one of acute the other of chronic inflammation of these valves, that places 
the two conditions in marked contrast. 

The first is reported by Dr. Graves, 5 of a man with pneumonia and par- 
tial solidification of the right lung. The disease remained stationary for 
about three weeks, then there occurred a sudden change for the worse, and 
the patient died in twenty-six hours. Inspection showed the pulmonary 
artery filled with a fibrinous clot. There were only two valves, and these 
were coated with a recent deposition of lymph, in some situations almost a 
quarter of an inch thick. The valves were much thickened and opaque, 

1 Guy's Hospital Reports, 3d series, vol. iii. p. 257. 

2 Wilks' Lectures on Pathological Anatomy, London, 1859, p. 93. 

3 Cases of Disease of the Pulmonary Artery and its Valves, by Gt. Whitley, M. D., 
Gruy's Hospital Reports, 3d series, vol. iii. p. 257. (Plate VII. Fig. 2.) 

4 Med.-Chir. Transactions, vol. xx. p. 94. 

5 Dublin Journal, vol. xxii. p. 388. 



I860.] Pathological Society op Philadelphia. lit 



contrasting in a remarkable manner with those of the aorta, which were 
quite free from disease. 

The second, a case of chronic inflammation of the pulmonary valves, is 
to be found in the Archives Generates de Medecine for 1844, 1 and was 
that of a girl, aged eighteen, who had presented for a long period symp- 
toms of organic disease of the heart. At the inspection the right ventricle 
was very much distended, with hypertrophy of its walls. The pulmonary 
valves were thickened in an extraordinary manner. They were rigid, ten- 
dinous, and of a grayish-yellow colour. The tricuspid and bicuspid valves 
were converted at their free border into a tendinous substance, and covered 
with numerous irregular vegetations. 

On the subject of vegetations on the pulmonary valves, Corvisart 2 has 
reported a case in a woman, aged twenty-five, in which a great number 
were found. Three cases of vegetations, two of which were so large as to 
obstruct the pulmonary orifice, are to be found in the Guy's hospital 
reports. 3 

Cancer of the Rectum of exceedingly small size; enormous accumula- 
tion of Fat in the Abdomen. — Dr. Packard reported the following case : 
George Smith, set. 59, an Englishman, was first seen by me in June, 1859. 
He was then very much blanched and emaciated, and extremely weak, com- 
plaining of constant pain and bearing down in the rectum ; there were very 
frequent discharges of flatus, and of small quantities of mucus. Occasion- 
ally a mass of white scybala was passed, with much pain. Several fistulas 
existed about the anus, and some haemorrhoids. Within easy reach of the 
finger there was a stricture of the rectum, irregularly nodulated, firm, and 
barely admitting the point of my forefinger ; this stricture I thought to be 
cancerous. 

His mind seemed somewhat impaired by suffering and debility, and the 
only available treatment was of course by a combination of stimulants, 
tonics, and anodynes. After attending him for some time I lost sight of 
him, or at least saw him at long intervals only. On the 7 th of March he 
died, according to the account of his attendants very quietly, and probably 
from sheer inanition. 

Assisted by my friend, Dr. Dunton, I made an examination of the body 
forty-eight hours after death. 

There was no rigor mortis ; the skin was very pale, smooth, and desti- 
tute of hair, except upon the face and about the pubes. The subcutaneous 
fat formed an excessively thick layer, and a like deposit existed everywhere 
beneath the peritoneum ; the appendices epiploicas were very numerous and 
large. All the tissues were abnormally pale and soft. 

The stomach was pale, flabby, and easily torn ; the intestines nearly 
empty, their walls very thin and soft, but without any other sign of dis- 
ease ; the colon was very much contracted throughout. The rectum was 
encased in an enormous quantity of fat, and strictured by a thread-like de- 
posit of fibro-plastic matter. The liver was nearly white, and seemed almost 
like a mass of tallow, so extreme was the fatty degeneration it had under- 
gone. The kidneys were embedded in a very large quantity of fat, and 
their structure was degenerated ; under the microscope some of the tubuli 

' Tome v. p. 364-5. 

2 Lesions Organiques du Coeur et des Gros Vaisseaux, Paris, 1318, p. 232. 

3 Third series, vol. iii. pp. 256, 259, 260. 



118 



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[July 



were of normal appearance, but many of them contained large oil-drops, and 
some of them were entirely empty: the epithelial cells contained clusters of 
minute oil-drops. The supra-renal capsules were pale, and their walls very 
thin. The spleen was healthy, but very small, and lighter -coloured than 
usual ; the pancreas was quite healthy. 

Thorax. — The pleural cavities contained some liquid, the characters of 
which were not clearly made out. because the thorax was entered through 
the diaphragm. Both lungs presented spots of a white deposit, upon their 
surfaces only: the mass of each organ was pale, except posteriorly, where 
hypostatic congestion had taken place. The deposits were few in number, 
and of variable size ; a line of them, upon the anterior surface of the left 
lung, caused a depression parallel to the division between the two lobes, an 
inch or two above this fissure, as if there had been a rudimentary separation 
of a middle lobe. This white deposit, examined microscopically, presented 
forms which resembled the ordinary cells of cancer. 

The heart was loaded with fat, and its muscular structure had undergone 
fatty change to a very marked degree. Its columns carnea? were singularly 
subdivided, so that each column was very small, and the interior presented 
an unusual aspect. All the valves were healthy. 

Complete ossification of the costal cartilages had taken place. 

Microscopically examined, the deposit about the rectum, which was so 
tough that its structural elements could scarcely be separated by tearing 
with needles, was found to consist of very fine wavy fibres, many of them 
with eloD gated, nucleolated nuclei. These fibres were very long, and arranged 
in bundles. 

The deposit in the lung was evidently degenerated to a great degree; but 
the very irregularly shaped large cells, with one or more large nuclei, con- 
taining single or double bright nucleoli, which were here and there visible, 
resembled those generally met with in cancer. Most of each mass was in a 
granular condition, and the fibrous walls of the air-cells and tubes could be 
readily traced. 

The case now detailed presents several features of marked interest. Its 
whole course resembled that of cancer ; and more than one gentleman, of 
far more experience than I could lay claim to, pronounced it positively to 
be of that character. And yet, although a priori any one would have 
looked to find an immense mass of disease, the whole of the adventitious 
deposit detected might have been contained in a teaspoon. 

The clinical symptoms — the emaciation and the want of healthy stools — 
may be accounted for in part by the disability for its function under which 
the liver must have laboured more and more. Nutrition being interfered 
with, the intestines wasted, the heart became the seat of fatty degeneration, 
the kidneys suffered in like manner, and perhaps the spleen dwindled as the 
blood-making process grew less and less active. The extreme contraction 
of the colon may be accounted for by the fact that it received nothing from 
the upper portion of the canal to distend it. 

But how are we to understand the enormous accumulation of fat in the 
abdominal subcutaneous and subperitoneal cellular tissue? The limbs were 
quite thin, and the thorax, so far as was ascertained, contained no abnormal 



I860.] Pathological Society of Philadelphia. 119 

fat, except what was connected with the heart. I confess that this pheno- 
menon does not seem to me to be easily explicable. 

Another difficulty is presented in reference to the order of sequence of 
the hepatic and rectal disease. Most probably they were simply coincident, 
perhaps coetaneous, but without any mutual connection, except that the 
rectal stricture may have aggravated the disturbance of nutrition due to 
the state of the liver. 

Dr. S. W. G-Ross stated, that he had at present a case of cancerous stric- 
ture of the rectum under treatment, in which the patient, although pale, 
was extremely corpulent. His abdomen especially was very large. 

Dr. Woodward called attention to the fact that a fat belly, with thin 
limbs, was the result of particular drinks. It is very common in some 
nations. 

Dr. Keller mentioned that the bodies of drinkers of pale beer in Berlin 
are thus shaped. 

Dr. Lenox Hodge reported that the patient, whose cancerous breast 
had been exhibited to the society (see Proceedings of Xovember 9, 1859), 
was again in the hospital, the cancer having returned. The specimen was 
one which had been pronounced, after careful minute examination, larda- 
ceous cancer. Its speedy return illustrated the malignancy of this form of 
the malady. 

March 28. Slit-like Perforation of the Aortic Valves, — This specimen 
was exhibited by Dr. Packard. The early history of the case was nar- 
rated by Dr. Kane. 

The patient was an Irish labourer, set. about 40, of medium height, and 
strong build; who for some years past had been addicted to the intemperate 
use of liquor. 

When I saw him for the first time, on the 8th of February last, he was 
lying in bed, with his shoulders propped up, and his head thrown far back, 
complaining of severe pains in the back of his neck. On my telling him 
to sit up, he did so with the aid of his wife, she raising him while he sup- 
ported his head with both hands. This, together with the peculiar attitude 
of the head, made me at first suspect caries of one of the cervical vertebrae ; 
but I found the vertebral spines prominent, and free from tenderness on 
pressure. There was, however, a slight amount of tenderness in the mus- 
cles, at the back part of the neck. 

The pulse was rather quicker and weaker than normal, the tongue coated 
with a thick blankety fur, the skin dry and harsh, the complexion sallow, 
and the bowels constipated. I noticed too a constant tremor of the head, 
which, however, the family told me was of long standing, having existed 
ever since a sunstroke, received some seven years previously. The family also 
told me that about five years before the illness under which he then laboured, 
he had been the victim of a severe attack of inflammatory rheumatism. 
Percussion gave a clear sound all over his chest, and his lungs seemed per- 
fectly healthy on auscultation. On listening over the praecordial region, 
however, a slight murmur was perceptible synchronous with the heart's 
systole, and seemingly clearest in the region of the apex ; but the exposed 
situation of the patient's bed, which was in a cellar, directly in the draught 
between two doors, made me unwilling to strip him ; and this, together with 
the constant noise which surrounded us, prevented my coming to a positive 



120 



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[July 



conclusion as to the exact seat of lesion, though I suspected it to be the 
mitral valve. Moreover, as there was no pain in the neighbourhood of the 
heart, I was inclined to refer any disease which might exist in that organ 
to the previous attack of rheumatism. 

I ordered warm fomentations and dry cups to be applied to the upper 
spine, and gave him a mercurial purgative, to which I added, as the urine 
was rather scanty and high coloured, a solution of acetate of potassa, to be 
taken three times daily, and a powder of nitre, opium, and ipecac, to be 
given at night. 

The next day my patient felt better ; his bowels were open, his skin soft 
and moist, and his urine abundant. His tongue, however, continued coated, 
and the pain in his neck was unabated. 

I attended this case for five weeks, during which time the pain in the 
neck continued with unvarying intensity, and the general symptoms re- 
mained unaltered. 

The principal treatment was alkaline ; but colchicum, guaiac, and iodide 
of potassium were all tried, and proved unsatisfactory. About the end of 
the third week, the patient growing weaker, and complaining of loss of 
appetite, cinchona and bitter tonics were added to the previous treatment. 
Local applications, such as blisters, dry and cut cups, warm fomentations, 
and stimulating counter-irritant lotions, were tried and retried, but with no 
apparent results. 

The last time I saw my patient his pain in the neck had suddenly lessened 
in violence, but only to be supplanted by equally severe pains in the chest. 
I listened to his heart at this time, and could distinguish no alteration in 
the original murmur. 

A severe attack of sore throat prevented my continuing in attendance on 
this case, which was taken charge of by my friend, Dr. Packard. 

Dr. Packard continued the account : When I saw this patient, on the 
11th of March, he was extremely weak, and was said by his friends to have 
eaten nothing of any consequence for a long time. He complained of great 
pain about the lower part of the thorax, on both sides. This I regarded 
as intercostal neuralgia or rheumatism, and ordered dry cups, the abstrac- 
tion of any blood being out of the question. A stimulating liniment, and 
the wrapping of the chest in raw cotton, were also employed, with some 
success. 

A day or two after, as he had had a painful watery passage from his 
bowels, with fever, and tenderness and enlargement of the liver, I ordered 
a blister over this organ, and some powders of ipecac, gr. -J ; hydr. chlor. 
mit. gr. ss ; and op. gr. J ; but they had very little effect. 

On the 16th, finding him very weak, with a dry, brown tongue, I ordered 
him a mixture containing ol. terebinth., rather in the hope of stimulating 
him, than with any other therapeutical view. He, however, sank and died 
that night. 

The autopsy was made twenty-two hours after death, Drs. Kane and 
Wurts kindly assisting me. 

Head. — The pericranium was very closely attached to the bone, which 
was thicker than usual. The meningeal vessels were somewhat distended 
with blood ; but the cerebral sinuses were for the most part empty. There 
was a good deal of serum beneath the arachnoid. The brain -substance was 
unusually dense, and a little congested. It seemed, as it were, saturated 
with serum, which dropped continually upon the floor, when the organ was 
held in the hand. Yery little serum was, however, found in the ventricles, 



I860.] Pathological Society of Philadelphia. 121 

which seemed quite normal. In the basilar artery, and in its afferent and 
efferent branches, there were firm clots, of a deep red colour. 

Thorax. — The lungs were healthy, full of air and frothy mucus. The 
heart was fatty, its substance being degenerated ; it was large and flabby, 
and in its ventricles were contained very large, pale, firm clots, quite closely 
adherent to the inner surface of the wall, as well as entangled among the 
columnae'carneas. All the valves on the right side were healthy ; on the 
left side the mitral valve was thickened and somewhat rigid. The semi- 
lunar valves of the aorta were, however, the seat of the greatest lesion ; one 
of them, behind which was the mouth of a coronary artery, was largely 
covered with vegetations, but an irregular perforation of the mass had in 
some way taken place ; both the others were torn down from the middle 
of their free edges, nearly to their place of attachment. Hardly any doubt 
could be entertained that this tearing had taken place some time before 
death ; but from what cause it would seem difficult to explain. 

Abdomen. — All the subcutaneous and subperitoneal fat was very abund- 
ant, but singularly irregular and straggling in the manner of its disposition. 
The liver was a good deal enlarged, and in a state of not very advanced 
fatty degeneration ; the gall-bladder dark coloured, but not very full. The 
stomach and intestines were apparently normal ; they contained nothing 
but mucus, and some bile. The spleen was large and rather soft, but 
healthy, as was also the pancreas. The kidneys were large and quite fatty ; 
the supra-renal capsules healthy. 

Dr. Hodge remarked, in reference to the heart-clots on the table, that in 
examining the hearts of patients who had died from acute injuries, and of 
those whose death was attributed to mania-a-potu, he had often found firm 
yellow clots, and desired the views of the society on two points connected 
with this subject : 1st. Can a clot form in the heart during life ? and 2d. 
Does the existence of a heart-clot necessarily cause death ? 

Dr. Packard said that he had no doubt of the fact that heart-clots might 
be formed during life, and that he regarded those found in the heart, from 
which the specimen had been taken, as of this nature. He added, that it 
was no uncommon thing, in making an autopsy, to find two varieties of 
clot in the same heart : one soft, purple, and resembling currant jelly in 
appearance, being evidently of post-mortem formation ; while the other, 
formed during life, has been washed perfectly clean and white by the circu- 
lating blood, and is so firm in consistence as to simulate organized tissue. 

Dr. La Roche observed, that he had found clots of both the varieties 
spoken of by Dr. Packard in the hearts of patients who had died of fevers, 
where the autopsy was made so soon after death as to preclude the idea 
that they were of post-mortem formation. Yet, there had been no symp- 
toms during life to indicate their existence. He, therefore, argued that 
heart-clots might exist without producing death, and further expressed the 
opinion that the clots found in the hearts of fever patients, especially yellow 
fever patients, were generally formed long before death ; for in these cases 
the blood is known to be not very prone to clot. Indeed, it will scarcely 
do so at all, unless whipped. Now, the whipping action of the heart almost 
entirely ceases for some hours before death, owing to the slow action of the 
organ, and yet the clots are found to be remarkably firm. 

Wound of the Stomach. — Exhibited by Dr. Reed. A. B., coloured, 
twenty-two years of age, was brought into the Pennsylvania Hospital 
about 12 o'clock on Saturday night, the 24th of March, very much pros- 
trated, and bleeding from a large wound in the left side, through which 



122 



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[July 



a part of the omentum protruded. He had evidently lost a great 
deal of blood, was nearly pulseless, and his sufferings were extreme. 
He was exceedingly restless, turning from side to side. He had been 
stabbed in the street, was found lying on a cellar door, and was taken at 
once to the hospital. The omentum was returned, and the external wound 
closed with lead sutures, and compresses and broad strips of adhesive plaster 
passed half way round the body, and a bandage passed over all, entirely 
round the body. He vomited while his wounds were being dressed, 
and afterwards several times. There was no evidence of blood in the sto- 
mach ; the breathing was hurried and difficult, about 56 to 60 in the minute. 
The water had to be drawn off by a catheter. Brandy and opium were 
given in full doses, principally by injection. Up to 5 o'clock in the morn- 
ing, 410 drops of tinct. opii were administered — one dose of 50 drops by 
mouth, and three injections of 120 drops each. As the pulse was flagging, 
the patient was stimulated freely. At bh o'clock, he fell into an uneasy 
sleep. At t| o'clock the respirations were 50 per minute. At 10 o'clock, 
he was awake ; sensible, though restless. He had not vomited since 3 
o'clock A. M. The belly was tympanitic. At 12 J- o'clock the patient was 
seen by two of the attending surgeons. There was no change. He com- 
plained of pain in abdomen, and great thirst ; the pulse was quick and 
feeble. At a quarter before 4 o'clock, he was in articulo-mortis ; had lain 
quite still for an hour or two, and had then suddenly raised himself up to 
pass his water, when he sank back, and died in a few minutes. 

Post-mortem examination sixteen hours after death. — Small superficial 
wound in front of the left arm. 

A penetrating oblique wound, about two and a half inches in length, on 
left side of thorax, downwards and outwards. On making a longitudinal 
incision through abdominal walls, a large quantity of reddish serum filled 
the cavity of peritoneum ; deep congestion of the intestines and deposit of 
discoloured lymph, and some of the contents of the stomach were found 
upon the surface of the liver and bowels. 

Thorax. — Left lung partially collapsed ; no wound of lung. 

Wound in cartilage of ninth and eighth ribs, three-quarters of an inch in 
length and about a quarter inch in width. 

Wound in diaphragm near lower edge, just at the angle where the dia- 
phragm passes off from the ribs to form the floor of the thorax. In 
the wound of the cartilages the gastro-colic omentum was found engaged, 
filling it up entirely. Omentum confined entirely by cartilages, and not by 
the external muscle. 

Wound in stomach three-quarters of an inch long in the lower superior 
end of greater curvature ; mucous membrane everted ; some congestion of 
coats of stomach around wound ; no evidence of any hemorrhage into sto- 
mach ; large intestines contracted ; no wound ; coils of small intestines all 
glued together by lymph. The blood which escaped into the peritoneal 
cavity, as well as the contents of the stomach which passed out, no doubt 
caused the extensive peritonitis which was set up. 

The lymph deposited on the intestines was examined and found to be 
unorganized. That there was no vomiting of blood at any time, and no 
vomiting at all after the first three hours had elapsed, are interesting fea- 
tures in the case, showing the absence of two symptoms which generally 
accompany wounds of the stomach. The patient lived sixteen hours after 
the accident, under full doses of opium and stimulants. The extensive 



I860.] Pathological Society of Philadelphia. 123 



peritonitis, with such quantities of lymph deposited within so short a time, 
is an interesting example of how rapidly fatal such an acute attack may be. 

Dr. Woodward remarked, with reference .to the absence of vomiting of 
blood, that he had frequently made incisions into the stomachs of dogs 
without producing emesis of any kind. 

Dr. Gross observed that although vomiting had attended all the wounds 
of the stomach in the human subject which had fallen under his notice, yet 
he had not observed the presence of blood in the vomited matters to be all 
invariable. 

Dr. Robert P. Harris stated that he had met with a remarkable case 
of self-inflicted wound of the stomach, in which a large portion of the 
stomach was removed, the patient living for twelve hours. About thirteen 
years ago, a man of forty years of age, having heard upon his return 
from a sea-voyage of a few months' duration that his wife had been unfaith- 
ful to him, armed himself with a case-knife, entered his house very unex- 
pectedly to the object of his attack, and meeting her upon the stairway, 
plunged the weapon into her chest, turned it round in the wound and with- 
drawing it, left her dead at the foot of the stairs. Having accomplished 
this act he ran to an upper room, and with the same knife wounded himself 
in the right upper part of the umbilical region, making an incision through 
the abdominal wall of two inches in length, running in a direction down- 
wards and inwards towards the umbilicus. Through this wound he in- 
stantly dragged out the omentum, which, with its presenting attachments, 
he cut off close to the surface of the abdomen, and then commenced to pull 
out the next presenting body, i. e. the small intestine; but being inter- 
rupted by the entrance of a stranger, who had been attracted to the house 
by hearing the scream of murder ! given by the woman at the moment when 
the attack was made upon her, he cut off hastily what he had drawn out, 
before the man could get possession of the knife. 

When called to him I found him excessively pale and feeble, evidently 
suffering from internal hemorrhage, but wonderfully calm and composed, 
considering the nature of his injury, which I readily learned by examining 
the parts removed. These consisted of a large section of omentum, to 
which was attached a portion of the greater curvature of the stomach, 
measuring an inch and a half wide and two and a half inches long, together 
with about three feet of small intestine. The case being evidently hopeless, 
nothing was done but to close the wound and try to make the patient as 
comfortable for the closing hours of his life as possible. Without having 
been made aware of the nature of the internal injuries inflicted on himself, 
the patient informed me that he felt as if there was a hole in the bottom 
of his stomach, for that when he had taken a drink of cold water it seemed 
to him that it ran out, and he desired to know if there were no means by 
which his intolerable thirst might be quenched without drinking. This 
end was to a great degree accomplished by making use of a linen sop dipped 
in ice-water and putting it into his mouth. 

A very remarkable feature in this case was the wonderful composure of 
the patient, who did not manifest the slightest symptom of that want of 
fortitude so commonly met with in subjects who have received a wound of 
the stomach. Brave men, who could have borne to have had a leg or an 
arm shot off in battle without complaint, have been made to cry like child- 
ren under the depressing effect of a wound in the stomach. So great was 



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Proceedings of the 



[July 



the control of this patient over himself, that he scarcely appeared to suffer, 
except from weakness and thirst. He lived twelve hours after the receipt 
of injury, and died chiefly from the shock to the nervous system and the 
loss of blood internally. As there was no opportunity afforded for an 
autopsy, it could not be determined whether there was any commencing 
peritonitis or not. 

April 11. Spontaneous Cure of a Popliteal Aneurism. — Presented by 
Dr. Lenox Hodge. This specimen, of a spontaneous cure of a popliteal 
aneurism, was removed last July from a patient of Dr. Pancoast. When 
first seen by Dr. P., the aneurism was about the size of an English walnut, 
pulsating in the popliteal space. The man was 60 years of age, and was 
broken down in health from a tight stricture of the urethra, causing frequent 
retention of urine, and consequent inflammation of the bladder. On this 
account no operation was deemed advisable. Bellingham's compressors were 
employed for a time, but after a short and unsatisfactory trial were abandoned, 
on account of the uneasiness and oedema of the leg they occasioned. About 
two years afterward he had a chill, without any special cause that he knew of. 
From the time of this chill the tumour ceased to pulsate. During the two 
years its size had not varied in any marked degree ; as soon as the pulsa- 
tion disappeared, the tumour grew less ; and last summer, when he died from 
the disease of his bladder, nothing could be felt but a hard cord. The 
femoral artery was free and apparently healthy, as far as the superior 
articular branches of the knee ; for two inches below this it was a solid cord, 
and its diameter but a little greater than that of a normal artery in this 
region. The circulation appeared to have been perfectly kept up by means 
of the articular branches, which were all considerably increased in size. 

Extensive Fracture of the Skull ; Life prolonged for four hours. — Dr. 
Reed said : F. 1ST., sailor-lad, aged 15, was admitted into the Pennsylvania 
Hospital on Thursday, the 5th of April, at 11 o'clock A. M., in an in- 
sensible condition. His respiration was heavy, stertorous, and hurried ; the 
pulse full and slow ; the surface cold. He was exceedingly restless, requir- 
ing several persons to keep him upon the bed. He had been struck by a 
tackle-block weighing 200 lbs., which becoming detached from the mast- 
head some seventy feet high, fell, and the rope catching upon the gaff (a 
transverse beam at right angles to and half way down the mast) swung 
round and struck him a side blow as he stood upon the deck. 

On examining the head a very large depressed fracture was found over 
the left parietal and frontal bone, with fragments of bone evidently dis- 
placed. It presented the appearance as though the whole side of the head 
and face were driven in. There were great contusion and considerable 
ecchymosis, especially about the left eye ; but the ecchymosis was circum- 
scribed by the orbicularis palpebrarum muscle. There was also a fracture 
of the left radius. The patient's movements were principally confined to the 
left arm and leg ; the limbs of the right side seemed partially paralyzed, 
and some time before death, there was entire loss of power on that side. 
But little could be done for the patient, as he could not swallow. He 
gradually sank, and died comatose about 2J o'clock P. M., nearly four 
hours after the accident. An hour before death blood and part of the 
brain passed out of his nose. There was no bleeding from the ear. Pupil 
of the eye was dilated, but the conjunctiva not injected. 



1860.J Pathological Society op Philadelphia. 125 

Autopsy 30 hours after death. — On making an incision through the scalp 
the pericranium was found torn up, and the scalp loosened on a large part 
of skull ; large quantity of blood elf used beneath scalp ; the left parietal 
bone broken into some six or eight pieces ; coronal suture separated 
throughout its entire extent ; fracture extended into the right parietal and 
frontal bones. Blood-clots found upon the dura mater, and beneath it upon 
the arachnoid, and also beneath that membrane, especially at a point diagon- 
ally opposite the seat of injury. Anterior left lobe of brain was severely lace- 
rated; upon removing the brain the inferior vessels of the dura mater were 
found much engorged. On stripping off the dura mater from the base of skull, 
the fracture was found to extend through the occipital from left to right. 
Petrous portion of left temporal bone badly fractured ; in front the fracture 
extended upward through the orbital plate of frontal bone into the frontal 
sinus, also down into the cribriform plate of ethmoid bone. Through the 
hole made in this plate the blood and brain doubtless descended during 
life. No blood or serum in ventricles. All other organs were found healthy. 

There are several points of interest in this case to which I wish to call 
the attention of the Society. 

1st. The length of time the patient lived after such an accident — four 
hours. The great laceration of the substance of brain at the seat of frac- 
ture ; the very extensive fracture of the skull (which was of ordinary thick- 
ness) extending in three directions — one separating the coronal suture and 
extending into the parietal and frontal bones of right side, another from 
same point backward and downward through temporal bone and through 
the occipital bone over to the right side, a third issued through frontal 
bone into frontal sinus and downward through ethmoid — all show a terrific 
shock, from which it seems almost incredible that death was not instan- 
taneous. 

2d. The paralysis of right side coming on gradually. 

3d. The complete detachment of the coronal suture. 

Mh. The intense ecchymosis of the surface circumscribed by the orbicu- 
laris-palpebrarum muscle. 

5th. The great amount of hemorrhage upon the side of brain diagonally 
opposite the seat of injury. 

Qth. The entire absence of blood or serum in the ventricles of brain, and 
of hemorrhage from the ear. 

1th. The brain-substance being driven through the cribriform plate of 
the ethmoid into the nose. 

Cases of Diphtheritis. Case I. Diphtheritis with Pseudo-membranous 
Exudations in the Pharynx and Larynx. — Dr. Keller, in presenting the 
specimens said : Augustus Kieffer, nine years of age, a boy of healthy con- 
stitution, and of a very amiable disposition, had not felt very well for 
several days, when his mother took him with her to church on the 6th of 
April. On the 1th he became feverish and complained of sore throat. 
When I saw him on the morning of the 9th, I found him with a slight 
fever ; the tonsils were very much swelled, and partially covered with mem- 
branous exudations. The tongue was coated ; there was pain on swallow- 
ing, and a slight bronchial cough ; the voice was unimpaired. I ordered 



126 



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[July 



rest in bed, a purge, warm poultices around the throat, and frequent garg- 
ling with a strong decoction of white oak bark, alum, and honey. There 
was no change the next day. On the 11th he became aphonic, but there 
was no other sign of an affection of the windpipe. On the 15th, at midday, 
I heard a rough barking cough, which changed into a slight bronchial 
cough after drinking water. The respiration seemed to be normal ; the 
pulse was from 100 to 104. The mother told me that he had expectorated 
the day before a large portion of a skin-like substance. I touched his 
throat thoroughly with a solut. of nitr. silver (5j to |j). Towards evening, 
at six o'clock, the little patient, after expectorating some large pieces of 
pseudo-membrane of a white color, spotted with blood, had a severe strang- 
ling attack: yet a short time after I found him comparatively easy, without 
difficulty of breathing, his pulse 84. The membranous exudation consisted, 
under the microscope, of a large quantity of cells and coagulations, pre- 
senting the appearance of cellular tissue. I gave him a few powders of 
ipecac, which produced vomiting, though no other pseudo-membrane was 
ejected. 

During the night, which he passed quietly, he took senega and squill. 
On the 15th, in the morning, I found a normal respiration, pulse 80, great 
difficulty in swallowing, no appetite, tongue thickly coated, the tonsils cov- 
ered with pseudo-membranes. I touched his throat again with a solut. of 
nitr. of silver, continued the gargle of senega and squills, and gave him 
chloride of iron. In the evening he expectorated again pseudo-membranes. 

The nth, in the morning, the same difficulty in swallowing, 36 inspira- 
tions per minute, pulse 80, mucous rales in the lungs. In the evening, 
over 40 inspirations, a strong mucous rale in the tissue of the lungs, the 
pulse 104, easily compressible. 

The 18th, in the morning, at 5 o'clock, after vomiting several times, the 
patient became very weak, his pulse very irregular and small, and he died 
at ? o'clock of asphyxia. 

During the whole disease I had tried to keep up the strength of the 
patient by nourishing broths. 

Post-mortem examination was made 15 hours after death by Dr. Pack- 
ard, whose report is as follows : — 

Autopsy on Dr. Keller's patient, made April 19, 1860. 

Thorax and abdomen only examined. 

The epiglottis and the larynx generally were thickened ; the respiratory 
mucous membrane reddened; the larynx, trachea, and bronchi, were lined 
with a tube of false membrane, which began in the pharynx and extended 
into the smallest traceable ramifications of the air-tubes. The lungs were 
cedematous, not very crepitant, but floated in water ; the left pleura pre- 
sented very extensive adhesions at its lower part, the right only a few ; the 
right lung was more congested than the left. The left lung was divided 
into three lobes. 

The right auricle was full of clots, dark and soft, like currant jelly ; 
the right ventricle was also full of clots, white, firm, and adherent at the 
anterior part near the apex, but elsewhere dark and soft. These clots 
extended into the pulmonary artery and its branches, becoming paler and 
firmer towards their termination. The left ventricle less distended, but with 
a clot of the same kind ; a long, pale, firm cord passed down the aorta ; the 
left auricle was not much distended. 

The liver was very large, firm, but not much altered in color, and 
apparently healthy. The stomach was distended with a greenish liquid, 



I860.] 



Pathological Society of Philadelphia. 



121 



turbid, with yellowish flakes, and presenting a good many shreds of mucus. 
Other abdominal viscera healthy. 

The appendix vermiformis was at least six inches in length. 

Case II. Diphtherias without Affection of the Larynx and Bronchi. — 
Mrs. Jac. K., 31 years of age, of a very nervous disposition, was attending 
her son. affected by diphtheritis, from the 9th to the 18th of April, 1860, 
when she felt, immediately after his death, pain in her throat. On exa- 
mining in the morning, at 9 o'clock, I found a small spot, not larger than 
a millet seed, on the upper edge of the right tonsil. The mucous mem- 
brane was reddened, and secreted more mucus than usual. I ordered citrate 
of magnesia, and a gargle consisting of a decoction of white oak and alum. 
On the 19th Dr. Packard saw the case with me. The patient experienced 
a great deal of pain in swallowing, and we found both tonsils covered with 
pseudo-membranous exudation, and at the same time secreting a great deal 
of mucus. She complained of pains in the extremities j her pulse ran from 
100 to 120. I applied the nitrate of silver in substance, and ordered her 
brandy and broths for nourishment. 

On the 20th the white exudations had spread over the surface of the 
fauces as far as I could see down the throat. The secretion continued. 
Diluted Labarraque's solution was used as a gargle. On the 22d, the pain 
in the throat was intense. On the 23d the root of the uvula began to get 
covered with the exudations. I applied a solution of nitr. of silver (5j to 
On the night of the 24th the patient slept for the first time. The 
mucous membrane around and under the exudation was readily detached 
and easily made to bleed. 

On the 25th, the patient had a good night's rest, the fever had disap- 
peared, the pseudo-membranes were diminishing ; and there remained, on 
the 10th of May, only a small spot on the anterior surface of the uvula. 

Dr. Keller further spoke of a case which had come under his notice in 
which diphtheritic inflammation had first occurred in the vulva, and after- 
wards attacked the larynx by metastasis. He also remarked that the Ger- 
man population was especially liable to diphtheria. He was in the habit 
of relying much on blisters in the treatment of the disease, and he had had 
occasion to observe that those cases in which the blister showed a tendency 
to heal were more likely to prove fatal than those in which the blister ran 
freely. 

Fatty Degeneration of the Kidney — exhibited by Dr. Liyezet. — Henry 
McAnally, Eet. 46, born in Ireland, was admitted into the Pennsylvania 
Hospital on the 7th of April, 1860. He was a farmer, who had always 
enjoyed good health until about two months ago ; about which time he got 
wet and took a severe cold. He complained of his feet feeling very cold, 
and two or three days after he noticed that they were swelled, which swell- 
ing rapidly increased until it reached the abdomen, when he found that 
his urine had diminished in quantity. 

About a week before his admission, he perceived that his left hand and 
arm were slightly cedematous ; and he complained of an irritating cough, 
with some dyspnoea. 

The day after his admission the following note was made of his case : 
Percussion clear over the upper part of the chest, both anterior and pos- 
terior ; not so clear at the lower part posteriorly; and on the right side 
dull. Upon ausculting the patient over the upper and posterior part of 
the chest, respiration is found distinct, and louder than normal. Over 



128 



Proceedings of the 



the inferior angle of the scapula, on the right side, is heard a loud 
friction sound, with bronchial respiration ; these sounds are also heard on 
the other side, though not so distinct. Over the base of the lungs respi- 
ration is very faint, on the right side scarcely perceptible. Anteriorly 
bronchial respiration is heard throughout. Heart sounds louder than 
natural, but the impulse very feeble. Below the clavicle, on the left side, 
and apparently beneath the pectoralis major, appears a swelling, extending 
into the axilla, and impeding the venous circulation in the arm. This was 
first noticed by the patient about a week ago, and has slowly increased in 
size. 

The patient passes very little urine; sp. gr. 1009; very albuminous; 
under the microscope was seen a quantity of epithelium, with some oil, 
but no casts. 

Treatment. — To have stimulants, with infusion of juniper berries and 
cream of tartar, and warm bath and morphia at night. 

10th. Says he feels a little better; slept pretty well last night; has 
passed about three quarts of urine during the last twenty-four hours. 

12th. Examined the urine passed the night previous and found it to 
contain more albumen, and with fibrous casts containing granular matter, 
and some epithelium. The patient passed a restless night, and this morn- 
ing was found to be slightly delirious; he died about noon. 

Post-mortem examination eight hours after death. — Rigor mortis slight; 
whole body very oedematous; considerable discoloration of the skin over the 
left breast, from passive congestion. Upon dissecting up the tissues of the 
breast on that side, a large abscess, containing about half a pint of sanious 
pus, was found beneath the pectoralis major, extending into the axilla, and 
from the clavicle downward to the eighth rib. Upon opening the chest, a 
large quantity of clear limpid serum was found in both pleural cavities, 
rather more upon the left side. The left lung was free from adhesions, 
and appeared healthy, except at the apex, where posteriorly was found a 
small quantity of chalky deposit, in isolated spots ; near the middle and 
posterior part of the right lung were some pleuritic adhesions. The lung 
was very much congested, apparently in the first stage of pneumonia, the 
lower lobe was consolidated, with two small abscesses near the base of it. 

Heart. — Small and firm, with a firm clot in right auricle, extending into 
and interwoven with the chordae tendinee of the right ventricle, and sup- 
posed to be of ante-mortem formation. No clot in the left auricle or ven- 
tricle. Valves healthy. 

Liver. — Fatty, with right lobe mammillated ; left lobe small. 

Kidneys. — Large, firm, and waxy ; right one having an old cicatrix in 
the upper and posterior part ; the cortical portion presenting a granular 
appearance. Thin sections, under the microscope, showed waxy casts, 
some free, and others within the uriniferous tubules ; some of the tubes 
were also seen contracted and destitute of epithelium, others filled with 
epithelial cells containing oil. 

Spleen. — Slightly enlarged and very soft. Other organs healthy. 

Hourglass Contraction of the Stomach with TJiickening and Constric- 
tion of the Pylorus — presented by Dr. Livezey. — Ann Gallagher, aet. 40, 
a patient in the Pennsylvania Hospital, died April 22, 1860, of phthisis. 

Post-mortem examination ten hours after death. — Rigor mortis well 
marked. Upon opening the chest, pleuritic adhesions were found on both 



I860.] Pathological Society of Philadelphia. 



129 



sides. In the right lung were large masses of softened tubercle, and an 
abscess in the lower lobe. 

At the apex of the left lung was found a large cavity, communicating 
with two or three smaller ones, with tubercles scattered through the lower 
part of the lung. 

Upon the external surface of the heart were two large patches of 
Lymph, but not adherent to the pericardium, and no signs of inflammation 
of that membrane : valves of the heart healthy. On opening the abdomen 
the stomach was found very much enlarged, with the pyloric extremity ex- 
tending below the umbilicus, and presenting a distinct hour-glass contrac- 
tion, at about one-third the distance from the pylorus. The duodenum 
was doubled upon itself, and situated behind the constricted portion of 
the stomach. On attempting to pass a stream of water from the stomach 
through the pyloric orifice it passed very slowly, and on openiug the 
stomach found the pyloric valve very much thickened and constricted — 
the opening being only about one-fourth of an inch in diameter. The 
liver and kidneys healthy. The patient had presented no symptoms which 
would have directed particular attention to the stomach, while in the hos- 
pital. 

Abnormal Position of the Eight Kidney ; Dilatation of the Heart. — 
Exhibited by Dr. Packard, for Dr. William R. Ditxtox. Joseph 
Thompson, aet. 45. a native of England, following the occupation of a 
news-carrier, had enjoyed good health until the 26th of December. 1859. 
At this time, in attempting to make a public speech, his voice became 
husky, and he was unable to continue. His breath now became short, and 
he began to cough and expectorate : he noticed also a failure in his appe- 
tite and strength. 

These symptoms increased so rapidly, that he soon after obtained admis- 
sion into the Pennsylvania Hospital, where he remained more than two 
months ; but his condition was not materially improved during that period. 
Having left that institution, he came under Dr. Dunton's care on the 31st 
of March, 1860. 

At this time there was bulging of the precordial region : the heart's 
impulse was very faint, and the apex-beat at a lower point than normal ; 
the area of percussion-dulness large : the first sound of the heart was very 
feeble, but no murmur could be heard. Coarse rales were perceptible over 
both sides of the chest, anteriorly as well as posteriorly. 

His lower extremities, penis and scrotum, became very much distended 
by serous effusion, and gangrenous spots eventually appeared upon them. 
His urine was highly charged with albumen. 

On the 19th of April he died. 

The postmortem examination was made the next day, with the assist- 
ance of Dr. Packard. 

Thorax and abdomen only examined. 

Both lungs a good deal congested, but mainly at the posterior part, from 
position. Extensive and very firm adhesions of the pleura covering the 
lower two-thirds and base of the right lung ; very much slighter adhesions 
of left pleura, in which there was some serous effusion. 

Heart very large ; pericardium healthy. All the cavities were dilated, 
and the walls universally thickened, but not to an extreme degree : those 
of the left ventricle, and the septum ventriculorum, were about three-quar- 
ters of an inch in thickness. All the valves were healthy, although some 
atheromatous deposit had taken place about those of the aorta. The clots 
No. LXXIX.—Jlly 1860. 9 



130 Pathological Society op Philadelphia. [July 

in the cavities, and in the vessels generally, were dark and like currant-jelly, 
except at the anterior part of the right ventricle, where a whitish firm clot 
was adherent to the wall, and entangled in the eolumnae carnese ; it extended 
some little distance into the pulmonary artery. 

The aorta and its branches, as far as they could be traced, were athero- 
matous ; the veins everywhere healthy. 

The liver was very much enlarged, and closely adherent to the under 
surface of the diaphragm ; it contained a good deal of blood, but seemed 
to have undergone no morbid change. On its under surface, in a rather 
deep fossa, lay the right kidney; its long axis was horizontal and antero- 
posterior, and the supra-renal capsule lay at its posterior extremity ; the 
peritoneum formed a suspensory ligament at each long border of the kidney, 
the two meeting at the apex of the capsular organ. 

The other kidney lay in its normal position, and, like its fellow, was 
small, but seemed healthy. In the supra-renal capsule of this side (the 
left) was what looked like a blood-clot of some age ; both capsules seemed 
larger, more solid, and more tabulated than usual. 

All the other abdominal viscera were healthy. 



I860.] 



131 



REVIEWS. 

Art. XIII. — Therapeutics and Materia Medica: A Systematic Treatise 
on the Action and Uses of Medicinal Agents, including their Descrip- 
tion and History. By Alfred Stille, M. D., late Professor of the 
Theory and Practice of Medicine in the Medical Department of Penn- 
sylvania College, &c. &c. Philadelphia : Blanchard & Lea, 1860. In 
2 vols. 8vo. pp. 813, 975. 

Among the various methods of writing a work on therapeutics and 
materia medica, two stand prominently out as the best. One gives the 
results of original research and experiment ; the other, without much or 
any original investigation, presents the results of compilation and com- 
parison. The former is an endeavour to enlarge our knowledge, in the 
direction of therapeutics, by detailing original experiments and observations 
that go to fix, with greater or less exactness, the laws of the action and 
uses of medicines. The latter aims at the same object, by comparing and 
analyzing the experiments and observations of others. This is not the 
place to inquire which of these two methods of investigation demands the 
highest order of talent, or which renders to science and art the largest 
service. Both require abilities, which, though widely different, are such as 
few are gifted with ; and both require, in addition to these natural gifts, a 
patient industry that flags under no labour, and a courage that fears no 
task. These two methods of investigation are complements of each other. 
Both render to medicine an indispensable service. In works, like that of 
Briquet on cinchona and its alkaloids, of Becquerel on electricity, of Que- 
venne on iron, and to a considerable extent that of Mr. Headland on the 
action of medicines, we have examples of the first of these methods of inves- 
tigation. In the work whose title we have placed above, we find an excel- 
lent example of the second. 

By thus distinguishing the elaborate treatise of Dr. Stille, on therapeu- 
tics and materia medica, as a sort of compilation, we mean no disparage- 
ment of its merits. We simply define its position. We only assign to it 
its place. Indeed, as we have already intimated, it would be difficult to 
decide who renders the largest service to science, the original investigator, 
who extends the area of our knowledge by personal experiment and observa- 
tion; or the conscientious scholar, who patiently collects the records of 
other's labours, carefully sifts the wheat from the chaff, and with judicial 
impartiality selects what is of greatest value from their opinions and their 
facts. This is what Dr. Stille has attempted ; and this he has accomplished 
with singular success. By styling his work a sort of compilation, there- 
fore, we do not mean that he has simply quoted the opinions and experi- 
ments of a great variety of medical authorities, bringing them into a confused 
juxtaposition, and so patched up or woven together a new medical book. 
We do not mean this. We mean that his treatise is the result of a patient, 
laborious, intelligent, and comprehensive research into the records of ancient 



132 



Reviews. 



[July 



and modern medicine ; that it exhibits a careful collation of an immense 
number of facts ; that it is, in short, an admirable digest of our present 
knowledge of therapeutics and materia medica. 

Such is a general statement of what the work is. Let us now examine 
it somewhat more in detail. 

On the title page it is described as "a systematic treatise on the action 
and uses of medicinal agents, including their description and history." This 
gives, so far as a title can, a sufficiently clear notion of the contents of the 
work. But the title is somewhat too comprehensive. Medicinal agents 
include a large number of remedies beside drugs. "Foods," says Dr. Cham- 
bers, "when administered to a sickly body, with the intention of restoring 
health, are medicines." The truth of the statement is too obvious to be 
doubted. Not only foods, but many other agents, that cannot be found on 
the druggist's shelves, become in the hands, or by the direction of a rational 
physician, medicines. These, from the title of "medicinal agents," we might 
expect to find discussed in Dr. Stille' s work. They are not. His treatise 
is concerned almost wholly with drugs. In his introduction he refers to 
the remedies alluded to, which he has not described, and gives his reasons 
for excluding them from his consideration. His reasons are valid enough, 
but they do not make the title of his work any more definite. This, how- 
ever, is a small matter, and we are not disposed to quarrel about it. 

The two volumes open with an introduction of one hundred and twenty- 
four pages. In this part the author treats of the sources of our knowledge 
of therapeutics ; the modus operandi of medicines, including their absorp- 
tion, and their physiological and therapeutical action ; the various methods 
of administering drugs, the circumstances which modify their action, and 
the art of prescribing. The introduction concludes with an account of the 
author's classification. These matters are necessarily treated with great 
brevity. A discussion of them forms an indispensable preparation to any 
careful study of the materia medica, and we only regret that Dr. Stille did 
not enter somewhat more fully into an examination of some points which 
he has barely touched upon. We refer particularly to the sort of changes, 
which drugs are liable to undergo after absorption; the new combinations, 
which it is possible for them to enter into in the human system ; the 
varying periods of their stay in the blood or tissues ; the processes of 
elimination; and, in short, the laws which govern the progress of a drug, 
after its introduction into the system, until its final departure through 
some of the secreting organs or membranes. These are all practical 
matters. It is true that they are poorly understood at present. Our 
knowledge in this direction is limited. Yet whatever is known, or can be 
hinted at, should be presented to the profession. Dr. Stille is evidently 
qualified for the task. 

The main body of the work is, of course, devoted to a description of 
medicinal agents. These the author brings together "in groups corre- 
sponding to their sensible operation upon the economy," and thus forms 
his classification. Twelve groups or classes are made to comprise all the 
agents he examines. Beginning with lenitives, or "medicines which allay 
local irritation," he describes in the following order : astringents, irritants, 
tonics, general stimulants, cerebro-spinal stimulants (narcotics and anti- 
spasmodics), spinants, general sedatives, arterial sedatives, nervous seda- 
tives, and alteratives. Classification belongs to the opprobria of writers 
on materia medica. From the medicamenta of Celsus to the esstomatics, 
ecbolics, adenagics, etc., of the learned Dr. William Tully, writers have ex- 



I860.] 



Stille, Therapeutics and Materia Medica. 



133 



hausted their ingenuity in classifying remedies. Probably no satisfactory 
classification, in the present state of our knowledge, is possible. That of 
Dr. Stille, which follows the most ancient models (with slight variations), 
is perhaps as good as any. At any rate, he has disarmed criticism with 
regard to it, by the frank admission that "in presenting this arrangement 
of the materia medica, the author is not only aware that it is obnoxious 
to criticism, but he is quite alive to its numerous defects." We will only 
express our regret, therefore, that he has retained the term alterative, which 
carries with it no definite meaning whatever, as the name of a class. If he 
had substituted for it the word unclassified, the term would have had, at 
least, the merit of hinting at no theory, and thus have been open to no 
misconception. And if, moreover, the group of unclassified had been en- 
larged, so as to contain certain agents, such, for example, as electricity, oil 
of turpentine, water in varying temperatures, ergot, and others that might 
be mentioned, he would not have been obliged to drive these into classes, 
which they do not willingly enter, and where their resemblance to their 
companions is by no means remarkable. We think a change of this sort 
would contribute to the simplicity of his classification, and to its practical 
value. Judged from a practical point of view, any classification is certainly 
unfortunate, which compels a writer to ignore anesthetics as a separate 
class, to put into the same group chloroform and the sweet spirits of nitre, 
and to divorce the carbonate from the bicarbonate of potassa. 

The description of the individuals of each class is preceded by some 
general remarks on the characteristics of the group. In some instances, 
as in the case of general sedatives, these prefatory remarks occupy only 
the brief space of two small pages. In other cases, as in the preface to 
irritants, they reach the extent of seventeen or eighteen pages. They are 
always pertinent to the matter which follows, and reward a careful reading 
of them. We refer to them, because prefaces of this sort are too often 
passed by carelessly, as of little value. In reality, they generally point 
out the pith and core of the succeeding pages, and the reader should use 
them, as travellers do a guide, to show where what is best and rarest can 
be found. 

The real value of a work, like the one under consideration, depends, on 
the whole, however, upon the manner in which each individual article is 
treated. And it is here, more than anywhere else, we think, that the excel- 
lence of Dr. Stille' s treatise is manifest. It was not without design, we 
presume, that in its title therapeutics was made to precede materia medica. 
For each article is discussed from the stand-point of the former, and not 
from that of the latter science. We are told in the preface that — 

"The strictly scientific portion of the subject embraces the consideration of 
medicines in their physical, chemical, and physiological relations. Of these, the 
first and second are described so fully and accurately in works, which rank as 
medical classics, that it seemed unnecessary to discuss them at length in a trea- 
tise, whose point of view is rather at the bedside of the sick, than in the labora- 
tory or the lecture-room." 

Accordingly, the physical properties and chemical relations of drugs are 
described with great brevity ; while their physiological action, on animals 
as well as on man, are examined with care, and oftentimes at consider- 
able length. Next follows an account of their therapeutical value and 
applications. 

This is as it should be. The only proper way to study that portion of 
therapeutics, with which drugs are concerned — the only way by which any 



134 Reviews. [July 

sure advance can be made in a science, involved in so many complex rela- 
tions as therapeutics — is to study, first and accurately, the physiological 
action of medicines on the animal and human system. In their physiolo- 
gical action is to be found, not always a sure indication, and sometimes no 
indication at all, for their remedial employment; but the best and safest 
guide for their management, for their exhibition in the diseases to which 
they are applicable. Thus, from the physiological action of quinia, in 
large and small doses, from its powerfully sedative influence over the nervous 
system and the heart, from the changes which it induces in the blood, from 
the rapidity of its absorption, and the facility of its elimination, and the 
ratio of elimination to absorption, we could not infer its value in periodical 
and pyogenic diseases. Yet, when clinical observation has demonstrated 
the latter, or its therapeutical value, we get from the former, or its physio- 
logical action, a perfect guide for its administration. Its physiological study 
reveals the art of its administration, and hints significantly at its modus 
operandi. Any writer on materia medica, at the present day, who, in 
describing cinchona and its alkaloids, should omit its physiological action, 
would be guilty of the gravest neglect. Xow, what is true of cinchona in 
this respect, is true, to a greater or less extent, of every article in the Phar- 
macopoeia. And hence the importance of restudying, with all the aid that 
science can lend, most of the articles which form the armamenta medicorum. 
Dr. Stille's treatise bears ample evidence that he is fully aware of the im- 
portance of doing this. In every instance, and we do not remember to 
have noticed an exception, he has given the latest results of European and 
American observers as to the action of the articles, which he describes on 
animals and men in health. When this has been given, then follows in 
due order their remedial employment. If, in the case of many articles, only 
a meagre account of their physiological action can be found, this is owing 
to our present imperfect knowledge, and not to any negligence on the part 
of the author. It is because we are still sadly ignorant with regard to 
many drugs, that we are daily using at the bedside. 

We have been gratified at finding the medical history of each drug, or 
what might be termed its biography, presented to us by way of introduction 
to the physiological action just alluded to. The history of an article, which 
a physician employs, is not only a matter of interest to him ; it is often of 
great utility. The method by which a medicine is introduced to the pro- 
fession ; its sudden or gradual reception into favour ; the various changes to 
which it has been subjected from one age to another ; the different names 
by which it has been known ; the different purposes to which it has been 
applied ; the different virtues which have been ascribed to it ; these, and 
other matters connected with the history of a drug, are important, not 
merely because they are curious in themselves, but because they serve to 
guide the practitioner oftentimes in his selection and use of remedies. We 
think Dr. Stille was wise in devoting a portion of his work to this subject. 
In doing so he has given us much curious and valuable matter, and always 
in an attractive form. As an illustration of what we refer to, and a fair 
example of the author's style, we take pleasure in quoting a portion of his 
account of the history of an article, comparatively new to American phy- 
sicians, the cannabis Indica. We learn from him, that 

" The Chinese were acquainted with hemp, as an anaesthetic, as early as the 
third century of the Christian era. According to Stanislas Julien. a celebrated 
Chinese physician, named Hoa-Tho (A. D. 220), operated on his patients, after 
having rendered them insensible by means of a preparation of wine and hemp 



I860.] Still e, Therapeutics and Materia Medica. 135 



powder (Martins) , or, adopting another version, by means of hemp alone. Then, 
according to the case, he made openings and incisions, performed amputations, 
and removed the cause of mischief; he then brought together the tissues with 
points of suture, and applied liniments. 

" About the eleventh century of the Christian era, there arose in Persia the 
famous sect of the Assassins. The persons held to be worthy of membership 
in this bloody community were subjected to the most seductive impressions, 
while under the influence of the haschisch. and led to believe themselves the 
chosen instruments of a supernatural power. The chief of the sect alone pos- 
sessed the secret of its use. The novice was invited to his table, and there in- 
toxicated with this substance. He was then carried into a delicious garden, 
where he enjoyed, as a foretaste of heaven, all those sensual and enervating de- 
lights which the Prophet has promised to his followers. At last, overcome by 
them and the narcotic influence of the drug, he was removed to his former 
situation, and on awaking was persuaded by his wily tempter, as well as by his 
own recollections, that he had partaken of the bliss of Paradise. Haschisch 
was used to produce a pleasurable intoxication, a state of ecstasy, and not, as 
some relate, for the purpose of throwing those to whom it was administered, into 
a state of madness and frenzy, during the continuance of which they performed 
the most barbarous actions, and, running a muck, became promiscuous assassins. 
The derivation of the word is in this wise : Haschischa, which signifies merely 
plant, became the title of this, which was esteemed the most excellent or potent 
of all plants, and from it the name Haschischin was derived, to distinguish those 
who, by means of its intoxicating properties, were initiated into the mysteries 
of the sect. Hence the modern word assassin, has come to signify one guilty of 
the peculiar crime of the Haschischin. The mischievous effects of haschisch are 
said to have caused its prohibition in Mohammedan countries until the fifteenth 
century, when Sultan Ahmed permitted its use, which soon became general, 
and, according to the historian, brought on the corruption and degradation of 
the human race. Ebn Baithar states that in large doses the drug induces ex- 
treme lassitude with delirium, that its habitual use weakens the intellect in a 
remarkable manner, and that excessive doses produce a maniacal condition, ter- 
minating in death. Its effects were witnessed at Amboyna, by Eumphius, in 
1695. He calls it herba stultorum, and says that throughout India the leaves 
and seeds are extensively used to dispel anxiety and excite agreeable dreams ; 
that a maniacal state sometimes ensues ; that he has known it cause, when 
smoked with tobacco, a frantic pugnacity in some, sardonic grins and menaces 
in others, and lamentations in others. Nearly the same effects are ascribed by 
Chardin to the immoderate and protracted use of the drug among the Persians. 

" But the use of hemp to produce intoxication is not confined to the Orientals. 
The plant is said to be cultivated by the Hottentots for the purpose of smoking 
only, and it is used in like manner by the negroes of Brazil, who doubtless brought 
the habit with them from Africa. In Eussia, Poland, and other neighbouring- 
countries, the peasants are extremely fond of parched hempseed, which they eat 
upon black bread, with a little salt, and even the nobles of these regions, when 
hunting or travelling, find it an agreeable condiment. It is related, that remain- 
ing long or sleeping in a field of hemp has produced feebleness of sight, vertigo, 
and intoxication. But such power in the hemp of temperate or cold climates 
may farely be called in question, for the product in which the active properties 
of the plant reside scarcely exists beyond the regions which lie within or border 
upon the tropics In 1839, attention was called to the pro- 
perties and medicinal virtues of cannabis, by Dr. O'Shaughnessy, Professor of 
Chemistry in the Medical College, Calcutta, who had enjoyed many opportunities 
of studying its effects in disease, and of witnessing the phenomena occasioned 
by it, when used to produce intoxication. Subsequently, its virtues were tested 
by numerous competent observers, who made good its claims to a permanent 
place in the materia medica." — Yol. ii. pp. 77-80. 

We should do injustice to the work not to refer to the number of authori- 
ties which the author has quoted from. In his various descriptions, and 
especially in his account of the physiological and therapeutical action of 



136 



Reviews. 



[July 



each article, lie has drawn largely upon the best medical literature of the 
world. And this he has done in no superficial manner. The author is 
a scholar in the best sense of that word. He is evidently familiar with the 
medical literature of Germany and France, as well as of England and this 
country, and his pages often display a knowledge of the ancients, which, 
we are sorry to say, is a rare accomplishment among American physicians, 
if we judge them by their writings. Yet there is no obtrusive display of 
learning in his pages. True scholarship is always modest, and Dr. Stille's 
work is as free from pedantry, as it is rich with a generous culture. We 
know of no work on therapeutics and materia medica in the English 
language, where the opinions of so many and such widely different authori- 
ties can be found, placed side by side. The author has not only referred to 
these authorities ; he has given us their views and experience. This he has 
done, not so much by quoting their language, as by presenting a synopsis 
of their opinions, crystallizing their observations upon his own pages. 
Particularly have we been gratified with the frequency and extent of his 
quotations from German authorities. The German scholars are proverbially 
learned. The extent of their researches and acquirements is sometimes 
marvellous. Their medical, like their other literature, is often burdened 
with learning, and it is sometimes necessary to wade through a mass of 
useless lore in order to get at some new fact or valuable observation. At 
the same time, their writers are not infrequently full of fanciful speculations, 
or wild theories, as if much learning had made them mad. But after 
making due allowance for these and other peculiarities of German medical 
literature, it must be confessed that it contains a wealth of observation, 
and an accumulation of recorded experience, which no other surpasses, and 
which perhaps no other equals. That such is the fact, we think has not 
been sufficiently appreciated in this country. This mine of wealth has been 
left to a great extent unexplored by American physicians. London and 
Paris are familiar to our students who go abroad or remain at home; 
while, until recently, Berlin and Vienna have been almost ignored. And, 
therefore, we think that Dr. Stille has done a good service to our profes- 
sion, and at the same time has largely enriched his own treatise by intro- 
ducing freely into it the observations of German writers. We hope it will 
prove a stimulus to his readers, which shall excite them to a closer acquaint- 
ance with those to whom he has thus introduced them. We do not intend 
by the above remarks to imply that the author has given undue prominence 
to German writers, or that he has disregarded other continental, or English, 
or American authorities. He has quoted impartially from all. The reader 
is enabled to compare the opinions of the most distinguished therapeutists 
of this country and Europe, upon the action and value of the various articles 
discussed. Perhaps it is a matter of regret, that he has so often refrained 
from any decided expression of his own views, after he has stated those of 
other observers. Facts are clearly presented ; opinions from the best sources 
are impartially given ; and then the reader is left to draw his own conclusions. 

There is, of course, great diversity in the description of different agents. 
Some are passed over briefly, while others are discussed at great length. 
The most important parts of the materia medica, those agents which physi- 
cians use the most frequently and largely, are carefully and fully examined. 
In some instances, Dr. Stille has given so complete an account of the subject 
before him, as to make his description of it worthy the name of a monograph. 
His work, however, is not an encyclopedia of the materia medica. It does 
not include everything, nor pretend to do so. Much that is obsolete, many 



I860.] 



Stille, Therapeutics and Materia Medica. 



13T 



drugs that are useless or little used, are properly left out. This method of 
describing with great fulness and accuracy agents of the most value, while 
those of less importance are either briefly discussed or altogether omitted, 
is doubtless the most useful one. In the main we agree with him in his 
selection of articles to be described. He has omitted some, whose introduc- 
tion would have added to the value of his treatise, and admitted others 
whose absence few would have regarded. We think that a work which de- 
scribes suet, isinglass, and the common dewberry, should not have excluded 
elaterium, and podophyllum, podophyllin, or leptandrin. 

We have no desire to weary the patience of our readers by following the 
course of Dr. Stille's treatise in greater detail. Yet he has described cer- 
tain articles of the materia medica with such fulness and accuracy, that we 
feel obliged to perform the agreeable duty of directing attention to some of 
them. 

The subject of etherization, including a description of sulphuric ether, 
chloroform, and chloric ether, fills a space of seventy-two pages in the 
second volume. We cannot speak too highly of the manner in which this 
important and difficult matter is treated. The history of ansesthesia is 
briefly and clearly traced, from its early faint foreshadowings in the natural 
magic of John Baptista Porta, along by many experiments of various 
scientific men, who, unconscious of the mighty blessing for the race which 
enveloped them as with a cloud, touched the great discovery and could not 
see it, to its birth at the Massachusetts General Hospital, in Boston, in 
1846; and thence we are shown its rapid course across the Atlantic to 
Europe, and its spread to the bounds of civilization. The claims of the 
two aspirants, Mr. Morton and Dr. C. T. Jackson, to its discovery are 
impartially presented, and decided in a way that is doubtless more conso- 
nant to justice than to the demands of the claimants. The physiological 
action of the inhalation of ether and chloroform is clearly stated, and the 
results of the latest and most trustworthy observers are given, so as to put 
the student in possession of whatever science has thus far brought to light 
on this important subject. The therapeutical value and uses of these two 
agents are laid down with equal care and clearness. The inconveniences 
and safety of ether, and the great power, convenience, and danger of chlo- 
roform, are well presented. We are not of those who expect to see the use 
of chloroform, as an anaesthetic, rapidly discarded, or who believe that it 
should never be used, yet we subscribe heartily to the following statement 
of our author : — 

"If we consider the minute precautions which are enforced by those who, like 
Dr. Snow, have had the largest experience in administering chloroform ; the 
abandonment or rejection of it by a large number of the most experienced and 
judicious surgeons in the United States ; the fact that the question of relinquish- 
ing it entirely has been proposed for discussion in the Surgical Society of Paris ; 
that besides the absence of all outward sign to indicate whether the patient is 
fit or unfit for the use of chloroform — in some cases the fatal effect is produced 
by an exceedingly small dose — and that the danger bears no proportion at all, 
or if any, an inverse proportion to the severity of the operation, it must be 
admitted that the question whether its use as an anaesthetic should be persisted 
in is one of extreme gravity, and which it is more than probable will ultimately 
be decided in the negative." — Yol. ii. p. 201. 

There are few drugs which physicians in this country, at least, use more 
frequently than quinia, or its salts. But, notwithstanding this fact, our 
medical men, unless we are greatly in error, know far less than they should 
of its physiological action. And yet its physiological action is the key to 



138 Reviews. [July 

its therapeutical use ; the only safe guide to its clinical exhibition. Dr. 
Stille has judiciously given a space of fifty-five pages to an account of 
cinchona and its alkaloids. The largest portion of his article is properly 
devoted to the physiological action and therapeutical use of the drug. He 
has quoted freely from the admirable and exhaustive researches of M. 
Briquet upon cinchona, and has thus conferred a large benefit upon those 
of his readers, who are unacquainted with the late work of the French phy- 
siologist. We will only remark, while commending Dr. Stille's article to 
the careful study of our practitioners, that his explanation of the modus 
operojidi of quinia does not appear to us to be "in harmony with the 
admitted facts of the case." We prefer that of M. Briquet. 

There are other articles, especially those on alcohol, cod-liver oil, can- 
nabis Indiea, anthelmintics, cold, veratrum viride, alum, and the modus 
operandi of astringents, which we should like to do more than refer to ; 
but our space allows only this brief allusion to them. 

In describing belladonna, Dr. Stille has examined the claim which is set 
up for it as a prophylactic against scarlatina, by the apostles of. the infini- 
tesimal theory of doses. The claim is by no means proven. Yet there is 
evidence enough in its favour to render it incumbent on the profession to 
investigate it carefully, and by extended and conclusive observations to 
prove or disprove it. It does not appear to us that the weight of evidence, 
which has been produced, tends to substantiate the claim, but the reverse. 
Still, there is some evidence in its favour, as well as much against it. The 
question is yet sub judice. More observations, and more careful ones, must 
be made, before a decision can be rendered. We think, therefore, Dr. Stille 
has wisely called the attention of his readers to this matter. At the same 
time we cannot assent to the test or criterion which he lays down as a 
means of deciding the prophylactic powers of belladonna. After giving a 
supposed case, which he states would not prove anything in favour of such 
powers, he adds : — 

"But, it is no less certain, if this substance (belladonna) were given to many 
families or portions of families during an epidemic of scarlatina, and, as a general 
rale, those who had taken it escaped the contagion, while a large proportion of 
those who had not taken it were attacked, it is certain, we say. that the protec- 
tive powers of belladonna against scarlatina would be unequivocally proven, 
although the exact degree of that power might not be determined.'* — Vol. ii. 
p. 49. 

We cannot agree to this. Neither do we believe that a careful observer, 
like Dr. Stille himself, would agree to it on further reflection, The formula 
is too general. It admits too much loose observation on a question, which 
requires the nicest discrimination and the most exact analysis. Judged by 
the above, we do not doubt that hyoscyamus and stramonium would be 
found to make out as good a case as belladonna. It is notorious, as our 
author states, that "in the case of scarlatina the degree of contagiousness 
is not ascertained ;" for many who are exposed to the contagion escape the 
disease. It is ascertained, however, that children take scarlatina more 
readily than adults ; that those who are exposed to it for a long time, living 
in the same apartment with it, are more likely to take it than those who 
are exposed to it only for a brief period ; that those who are constantly 
exposed to it, while living in close quarters and under bad hygienic sur- 
roundings, are more likely to take it than those exposed to it under oppo- 
site conditions. Dr. Stille's formula does not recognize these modifying 
circumstances. If he had done so, by some such statement as the follow- 



I860.] 



Stille, Therapeutics and Materia Medica. 



139 



ing, it would better answer the requirements of the case. If belladonna 
were given to many families, or portions of families, during an epidemic of 
scarlatina, and, as a general rule, those who took it, being of the same age, 
and similarly exposed and living under similar hygienic conditions, escaped 
the contagion ; while those who did not take it were attacked, being of the 
same age, and with the same surroundings, and having the same degree 
of exposure as those who did, then we should say "that the protective 
power of belladonna against scarlatina would be unequivocally proven." 
Judged by this rule, the observations we have met with do not favour the 
protective influence of belladonna. We have dwelt upon this matter at 
some length, because it is a most important one. It is one which, in the 
interests of humanity, ought to be determined, and can be, notwithstanding 
the difficulties which surround the problem, if competent observers would 
seriously set themselves to work about it. We trust that many such may 
be found. We know of no one more competent for the matter than Dr. 
Stille, and we are sure that in making his observations he would be more 
exact than his formula. 

We do not intend, by the foregoing remarks, to assert or imply, that no 
experiments have yet been made, for the purpose of ascertaining the sup- 
posed protective influence of belladonna, but only that those which have 
been made have not decided the question. And, therefore, we are glad 
that Dr. Stille has called attention again to the subject; though we believe 
that a careful analysis of the observations which have been placed on record 
up to the present time, do not sustain the claim, but go far to disprove it; 
and that properly conducted observations, made on a large scale, and so 
managed as to avoid all sources of fallacy, would demonstrate its inefficacy. 
This we should rejoice to see done, or rather to see the truth established, 
whatever that may be. 

Every close student of the materia medica, or rather every observer who 
devotes himself to a study of the physiological and therapeutical action of 
drugs, is in danger of falling into the error of regarding them as the chief 
agents in the cure of disease. If he does not believe them to be so, he is 
apt to talk and write about them as if they were. We have noticed with 
regret that so careful a writer and philosophical a thinker as Dr. Stille has 
not altogether avoided this danger. Throughout both volumes of his 
treatise, he uses the word "cure," with regard to the action of the drugs 
he describes, as if they initiated or carried on the processes by which dis- 
eases are gotten rid of, or cured. Thus he defines medicines, in the first 
line of the first volume, as substances which are "used for the cure of dis- 
eases." Dryden's definition (as given by Worcester), wherein a medicine 
is defined to be a "substance used as a remedy for disease," is more just. 
Frequently does our author associate with a drug the power of curing 
disease, as in the following instance. He is speaking of dropsy and the 
iodide of potassium, and remarks : — 

" Dr. Kissam, of Hartford, cured a case of the same description, and Bradfield 
one of ascites with oedema of the lower limbs by means of this medicine inter- 
nally, and an iodine liniment applied to the legs. It has also cured similar cases 
in the hands of Dr. A. T. Thomson, Dr. Camming, Dr. Stokes, and others. Dr. 
Sieveking cured hydrothorax, etc." — Yol. ii. p. 899. 

We do not mean to be hypercritical, and we do not think we are, in ob- 
jecting to this sort of language. It encourages a serious and widely-extended 
misconception of the powers of medical science, and the true position of a 
physician. This misconception of a physician's relation to disease exists 



140 



Reviews. 



[July 



in the profession as well as out of it, though we rejoice to believe that it is 
found more among the laity than elsewhere. We need not attempt to 
prove the inefficiency of drugs in controlling diseases. Every rational and 
philosophical student of disease knows that the processes, by which the 
economy expels it, may be aided by drugs, but that the latter are not gene- 
rally the chief agents or even assistants in so doing. In other words, the 
physician does not hold in his hands the power of curing disease. He is not 
responsible for the result of a malady whose course he superintends. His 
position is that of a guide over a road which the traveller must go; of a 
counsellor in difficulties which must be met, and which may kill ; and not 
that of a mechanic who engages to repair a machine, or of an architect who 
builds anew. Yet the latter is the common notion, utterly false as it is. 
This notion is kept alive, to a considerable extent, by the way in which the 
word cure is used; not in its etymological sense of cura, the cure of disease, 
but in a secondary and false one, which implies the existence of mysterious 
and occult powers in physicians and their art. It would add to the dignity, 
and enhance the usefulness of our profession, if the supposed power of drugs 
to cure infirmities could be exorcised out of the human mind. Language, 
which keeps such a notion alive, is to be regretted, and especially when it 
falls from the lips of a wise teacher and profound scholar. 

It is now time to bring this notice to a close. We have already extended 
it beyond the limits we assigned to it, when we took up our pen, and we 
fear that we have trespassed upon the patience of our readers in not reach- 
ing a conclusion sooner. And yet we have left untouched many points 
which we wished to discuss. If, however, we have succeeded in drawing the 
attention of any of the profession to Dr. Stille's treatise, we have done 
them a substantial service. We commend it heartily to them, as one of the 
best works on therapeutics and materia medica in American literature, and 
which will compare honourably with similar works in any language. Dr. 
Stille was well known, before the appearance of this treatise, as a scholar 
and observer ; this will add to his reputation both at home and abroad. It 
fills an important place among works on therapeutics, and we hope it will 
be largely studied. None can read it without advantage. We may add 
that its clear and simple style is not one of its least merits. In these days, 
when there is such a tendency to fine writing, it is delightful to come across 
an author who is not ashamed to use good old Saxon English ; who can 
crowd a book full of learning without pedantry ; and who evinces equal 
scholarship and modesty. 

The typographical execution of both volumes is excellent. It is perhaps 
needless to mention this, for the name of the publishers is a guarantee that 
whatever types and paper can do to commend the book to the reader has 
been done. A copious index, both of diseases and of drugs, closes the se- 
cond volume. The student will find the arrangement of foot-notes an ex- 
ceedingly convenient one for reference to the numerous authorities which 
the author has cited. E. H. C. 



I860.] 



Flint, Diseases of the Heart. 



141 



Art. XIY. — A Practical Treatise on the Diagnosis, Pathology, and 
Treatment of Diseases of the Heart. By Austin Flint, M. D., Pro- 
fessor of Clinical Medicine, etc., in the New Orleans School of Medicine; 
Yisiting Physician to the New Orleans Charity Hospital ; Honorary 
Member of the Medical Society of Virginia, of the Kentucky State Me- 
dical Society, of the Medical Society of Rhode Island, of the Pathological 
Society of Philadelphia, etc. Philadelphia: Blanchard & Lea, 1859. 
pp. 473, 8vo. 

It is a tradition in one of our medical schools that one of its most dis- 
tinguished graduates, who received his diploma nearly twenty-five years ago, 
presented a dissertation on diseases of the heart, and took for the motto of 
it a text of Scripture: "The heart is deceitful above all things." And yet 
at that time the subject had attracted attention, and distinguished patholo- 
gists of different countries had recently published the results of laborious 
investigations. The clinical treatise on diseases of the heart by M. Bouil- 
laud, the Professor of Clinical Medicine of the Faculty of Medicine of Paris, 
had just appeared. The second edition of Dr. Hope's "Treatise on the 
Diseases of the Heart and Great Yessels, comprising the Author's Yiew of 
the Physiology of the Heart's Action, as demonstrated by his Experiments 
in 1830 ; and an Appendix of his Experiments in 1834-5 on the Sounds, 
which have since been repeated by a Committee of the British Association," 
was published in 1835. M. Bouillaud, in the preface to his work, sketches 
the history of what had been done and said in the department of the ana- 
tomy, physiology, and pathology of the heart and the circulation. He- 
speaks of the labours of Yesalius, of Nicolas Massa, of Charles Etienne,, 
of Baillou, Lancisi, Yalsalva, and Albertini, of Morgagni, and of Senac. 
He thus comes to the time of Corvisart, of whom he says that he left far 
behind him all his predecessors. A new epoch is said to have commenced 
with the publication of the essay on the organic diseases and lesions of the 
heart and great vessels. In the editor's preface to that work it is said that 
"such a work must throw great light upon a class of diseases very little 
understood, though quite frequent ; it must manifest the numerous mistakes 
which have been committed by a vast number of physicians, both ancient 
and modern." Now, we must express some surprise that no allusion is 
made to Harvey, in this connection, by either of these writers. Both dwell 
on the importance of anatomical and physiological researches. Monsieur 
Bouillaud tells us that since the time of Bichat, Dupuytren, and Corvisart 
we have a remarkable instance of great progress made in medical science, 
because of the intimate union between anatomy and physiology and patho- 
logy. Broussais is spoken of as the worthy successor of Bichat and Corvi- 
sart, in establishing the intimate relations of these sciences.- The following 
passage from Corvisart is quoted: — 

"It would be a great mistake to believe that mere pathological anatomy is 
sufficient for the diagnosis of organic lesions. The physician who does not join 
physiology to anatomy may be a very skilful, industrious, and patient dissector ; 
but when called upon to treat disease, his practice will be wavering and uncertain. 
How many mistakes have I seen made at the bedsides of patients ! Disease 
attributed to the stomach or to the liver, when the heart or the lungs were the 
suffering organs ; and these organs declared to be the seat of disease, when the 
lesions were confined to the abdominal viscera, by persons possessed of a good 



142 Reviews. [July 

knowledge of anatomy, but whose acquaintance with physiology was limited and 
imperfect. And Broussais, in the preface to the Examination of Medical Doc- 
trines, says, emphatically, ' the characteristic features of diseases can be appre- 
ciated and laid hold of only through a good knowledge of physiology.' " 

Now, with such an appreciation of the importance of anatomy and phy- 
siology to successful pathological research, how does it happen that, in 
mentioning the names of those by whose labours the knowledge of diseases 
of the heart has been advanced, that of Harvey does not appear? By his 
own researches — by appreciating and putting in their proper connection the 
discoveries of others — a correct account of the circulation was given, and 
then only was it possible to lay the foundation of the pathology of the 
heart and its vessels. We have no space here to notice the views taken by 
some of what had been done by the immediate predecessors and contempo- 
raries of Harvey, leaving but little to him in perfecting what really was 
their work. We would refer to a very excellent article in the number of 
this journal for January. The name of Harvey has been and must be inti- 
mately associated with the knowledge of the heart and the Bloodvessels. 
Where can we now find a better description of the circulation, and of the 
movements of the heart, than is contained in his work? In the treatises of 
M. Bouillaud and of Dr. Hope the first chapters belong to the department of 
anatomy and physiology. What does the heart, how and why does it move ? 
These are the first questions with modern pathologists. The subject has 
been thoroughly reviewed by them, and with the effect of establishing the 
correctness and truth of the descriptions given two hundred years ago by 
him who well may be called the immortal Harvey. The French have been 
said to appreciate imperfectly whatever is done and said out of their own 
country and its capital ; and we must regard this omission to mention Har- 
vey's name in the works of two classical French authors on diseases of the 
heart, in both of which the true place is assigned to anatomy and physiology — 
that of being at the very foundation of pathology — as proof that the assertion 
has not been rashly made. We ourselves, living at a distance of three thou- 
sand miles from the arena of Harvey's life and labours, and with an interval 
of two hundred years, yet may be thankful to claim the affinity of race and 
country with so distinguished a man. And we cannot undertake the review 
of the work of our countryman and contemporary without magnifying the 
fame of one who may be said to have laid the foundation for all subsequent 
pathological researches. And we must note, too, the long interval between 
the acknowledgment of the truth of Harvey's results — between their general 
reception and the advances in pathological knowledge made by Corvisart 
and Laennec. Harvey recognized the sounds of the heart in 1628 ; Laennec 
called attention to their modification by disease in 1817 ; Monsieur Bertin's 
work, edited by M. Bouillaud, was published in 1824; and each subsequent 
year has brought researches and investigations which have been instigated 
by the successful results of the labours of those whose names we have just 
mentioned. A brief, condensed, but useful history of what has been done 
and written during the last forty years in cardiac anatomy, physiology, and 
pathology would be very interesting. England, France, Germany, Italy, 
and our own country have all brought forth zealous and successful labourers 
in this field; and the results and views and opinions' of scientific men living 
so widely apart might be so arranged, classified, and compared as to make 
an interesting chapter in psychology. Dr. Flint's book is what it professes 
to be, a practical treatise on the diagnosis, pathology, and treatment of 
diseases of the heart. He tells us in his preface that — 



I860.] 



Flint, Diseases of the Heart. 



143 



" In the preparation of this volume the aim has been to meet the wants of the 
medical student and practitioner, by the production of a work devoted exclu- 
sively to diseases of the heart, and treating concisely but comprehensively of 
these diseases, with reference to their diagnosis, pathology, and treatment." 

A little further on he says : — 

" In writing the book, the end which the author has kept steadily in view is a 
fair and full exposition of our present knowledge of the diagnosis, pathology, 
and treatment of diseases of the heart. Recognizing clinical study as the great 
source of this knowledge, he has endeavoured to make the cases reported by 
trustworthy observers, together with his own recorded experience, the basis of 
the work. Having long been in the habit of making records at the bedside, and 
having given for several years particular attention to diseases of the heart, he 
has accumulated notes of about two hundred cases of the various cardiac affec- 
tions. The results of an analysis of these cases have been before him during the 
composition of the work. As a preliminary step, also, over one hundred fatal 
cases, gathered from different authors, chiefly from the works of Hope, Stokes, 
Andry, and Blakiston, were subjected to similar analysis. On the data thus 
obtained have been based, in a great measure, the statements and opinions which 
the work contains, endeavouring, however, not to introduce details and statistics 
to an extent to prove repulsive or fatiguing to the reader." 

Dr. Flint is to be commended for his distinct recognition of the two 
sources of knowledge — the use of one's own powers of observation and 
reflection, and an acquaintance with what has been observed and thought 
by others. We must observe and think for ourselves in order to appreciate 
what is related by others, the fruits of their observation and reflection. 
There have been a great many observers and thinkers in this department 
of diseases of the heart, and Dr. Flint is well acquainted with the writings 
of many of these. He does not, however, refer as much to what has been 
said and done by French and German pathologists as to those of England 
and our own country, nor does he appear to have as well digested the results 
of their labours, the records of their opinions. Having constantly in view 
the wants of the medical student and the every-day practitioner, he has not 
been able to make it a thoroughly scientific treatise ; of which, we think, 
however, there is a great want at this present time, and which our author 
seems to us well qualified to supply. Such books are not popular, and find 
few readers. They are the basis, however, of a lasting reputation. They 
take a place in the permanent annals of science, whilst popular and practical 
treatises, widely circulated and read in their own day, are destined sooner 
or later to be replaced by new works of a similar character, in their turn 
to be disregarded and forgotten. 

Dr. Flint arranges his subjects with reference to the student and practi- 
tioner. He begins with enlargement of the heart, which generally is the 
result of causes long in operation, consequent upon other diseased processes, 
which have not been so appreciated by the patient as to induce him to ask 
medical advice. In hospitals and in private practice, cases of hypertrophy 
of the heart often present themselves. In our studies and researches we 
start from this point and go back to causes which frequently are diseases 
that may be referred to inflammatory or other processes. Most authors 
have first considered these affections. The history of pericarditis and endo- 
carditis — in the works of Messrs. Bouillaud and Hope, and Stokes — the 
lesions of the valves — are first set forth, and it is shown how they give rise 
to hypertrophy and dilatation of the heart. These two affections are very 
properly considered together by Dr. Flint, in the first chapter on enlarge- 
ment of the heart. The average weight and size of the healthy heart, as 



144 



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[July 



deduced from the researches of Bichat, Bouillaud, Ranking, Gross, and 
others, is first given, and then hypertrophy is taken up. We find an exact 
account of the situation and anatomical relations of the heart, deduced 
from an examination of dead bodies, and then it is shown how to ascertain 
the size of the heart during life. Attention is called to the superficial 
cardiac region, and to the deep cardiac region, and the student is told how 
to map out these two regions on the thoracic walls. Dr. Flint's own re- 
searches and those of Drs. Camman and Clark, establish the average extent 
of modified resonance during life, and thus form an important basis for the 
diagnosis of enlargement of the heart. The student is properly told that 
the ability to distinguish between hypertrophy and dilatation by the per- 
cussion-sound is more than questionable. Some remarks follow on the 
altered situation and extent of the apex-beat, and original researches on 
the centre and size of the area in which the impulse is felt, with the varia- 
tions as the patient may sit up or lie down, are very valuable. In remarks 
on the mechanism of the heart's impulse, the proofs that the heart is not 
shortened during the systolic contraction of the ventricles by an approxi- 
mation of the apex towards the base, from the researches of our own 
countrymen, Drs. Pennock, Moore, and Dalton, are brought forward and 
seem to us conclusive. The signs of enlargement and hypertrophy from 
the situation of the apex-beat, and impulses felt in other situations than 
over the apex, are well considered. The student is shown that he must 
not confound hypertrophy with inordinate activity of the heart — how to 
distinguish organic from functional disease. The abnormal modifications 
of the heart-sounds in hypertrophy are next considered. Here our author 
discusses the mechanism of the sounds of the heart, and refers to a fuller 
exposition of this subject in his prize essay on the clinical study of the 
heart-sounds in health and disease. This essay we look upon as a valuable 
contribution to science. It contains the results of original investigations 
leading to important results. The difficulty of distinguishing disease of 
the different valves where four of them are continually opening and shut- 
ting, is very great. And physiologists are not yet agreed as to the cause 
of these sounds, so much is rapidly taking place — auricular contractions 
and dilatations ; ventricular contractions and dilatations ; opening and 
closure of auriculo-ventricular valves ; opening and closure of arterial 
valves ; entrance and exit of blood from four cavities. How many of these 
operations are attended with sound ? When Laennec called attention to 
the sounds of the heart, and to their modification as signs of disease, he 
proposed a truly difficult problem, and how many experiments have been 
undertaken, how much has been written in attempts to solve it S Laennec 
did not comprehend and describe the action and sounds of the heart, as they 
are now established. He appreciated the first sound as isochronous with 
the contraction or systole of the ventricles, but he referred the second sound 
to the same period with the contraction of the auricles, and he placed the 
silence of the heart as between the auricular and ventricular systole. He 
speaks of the two sounds, of the one as the sound of the auricles, and of the 
other, as the sound of the ventricles. M. Andral thinks that he does not 
say that the sounds are dependent on muscular contraction. Has mus- 
cular extension or contraction anything to do with these sounds ? This is 
a question to which we find various answers, and which is an important 
one when we are seeking for signs of hypertrophy from the sounds of the 
heart. Dr. Flint speaks of the mixed nature of the first sound. He has 



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Flint, Diseases of the Heart. 



145 



carefully examined the sound in health as well as in disease. He says 
properly — 

"The results of accurate examinations of the healthy chest form, of course, 
the true and only basis of the clinical study of the normal heart-sounds. Scien- 
tific discovery requires, in addition to a competency for such examinations 
derived from a practical knowledge of physical exploration, sufficient carefulness 
of observation, and, also, that the facts observed be recorded and preserved in 
a form to admit of analysis. In pursuance of this plan for accumulating data 
for the investigation, I selected twenty-five persons presumed to be entirely free 
from cardiac disease. As evidence of the latter indispensable qualification, all 
the physical signs of disease of the heart were wanting, and, as an additional 
security, none had ever experienced an attack of acute rheumatism, or suffered 
from any grave affection of the chest. All were males, in perfect health, and, with 
a few exceptions, were between the ages of twenty and thirty. The examinations 
were leisurely made. In no instance was an examination of more than one 
person made at a time, and, repeatedly, the examination occupied two sittings. 
In part, the twenty-five examinations were made at different times, extending 
over a period of a year. The facts observed were invariably recorded at the 
moment of the examination. In all the examinations save three, I was assisted 
by a friend equally interested in the investigation, and an expert in physical 
exploration, by whom the accuracy of the observations was confirmed before 
being recorded." 

We have cited this passage as showing how thoroughly and carefully 
our author has studied the subject. He has thus made a permanent con- 
tribution to science in carefully recorded experiments, to show the variations 
of the sounds of the heart, as heard over different parts of the chest, the 
two sounds being compared with each other. He thus comes to several 
conclusions; one of which is that the first sound of the heart is a mixed 
sound when studied at the situation where its intensity is greatest, viz., 
over the apex of the organ. M. Magendie announced many years ago, as 
the result of his experiments, that the sounds of the heart proceeded simply 
from its stroke on the thoracic walls ; the first resulting from the stroke of 
the point of the heart in the intercostal space, and the second from a stroke 
of the ventricles of the heart against the sternum, taking place in their 
diastole. M. Andral was inclined to adopt this theory; but, the valvular 
theory suggested in 1831 by Billings, in England, elaborated a year later 
by M. Rouannet in Paris, was adopted by M. Bouillaud, and it is now 
almost universally conceded that the second sound of the heart is entirely 
valvular. In an article on the circulation of the heart in the April number 
of the British and Foreign Medic o-Chirurgical Review, the writer care- 
fully considers all that is taking place during the systole and diastole of 
the heart. He does not believe that the contraction or dilatation of the 
muscular substance of the heart is attended with appreciable sound. The 
passage of the blood through the heart and into the large vessels he believes 
to be noiseless. He does not believe that the impulse can give rise to a 
sound. The first sound, for him, is entirely valvular, and its difference 
from the second sound is to be explained by the difference between the 
auriculo-ventricular and semilunar valves and the difference of their situa- 
tion. Dr. Flint, however, calls attention to the variation of the first sound 
of the heart, as heard over the spot of the apex-beat or over that of the 
valves. He remarks that the first sound is almost invariably accentuated 
at the apex, the element of impulsion being almost constantly predominant, 
and also over the body of the heart ; whilst, at the base, the valvular 
element is the loudest, as well as over the right border of the heart, and at 
No. LXXIX.— July 1860. 10 



146 



Reviews. 



[July 



all the points removed from the precordial region when the first sound is 
appreciable. 

Pathologists who regard the first sound as valvular, do not dwell as 
much on modifications of the sounds of the heart as characteristic of hyper- 
trophy. Dr. Walsh — who admits muscular action, forcible shock of fluids 
against resisting membranes to be concurrent causes of the first sound, with 
valvular tension and impulse — says, " that in simple hypertrophy, the first 
sound is dull, muffled, prolonged, weakened, in some cases almost to virtual 
extinction, directly over the ventricle, the sensation reaching the observer's 
ear being rather one of impulsive motion than of sound ; under these cir- 
cumstances a tolerably full systolic sound may nevertheless frequently be 
found at the base and at the ensiform cartilage, the extent of its transmis- 
sion being very limited. During palpitation the first sound sometimes 
becomes comparatively clear." M. Grisolle says that hypertrophy of the 
heart is especially characterized by the violent impulse and the dulness 
and obscurity of the two sounds. M. Bouillaud, in his clinical lectures on 
diseases of the heart as reported by M. Auburtin, speaks of variation in 
the strength and extent of the impulse as the only physiological signs of 
hypertrophy. 1 Dr. Hope says that hypertrophy has the effect of deadening 
the sounds of the heart. " In simple hypertrophy, the first sound is duller 
and more prolonged than natural, in proportion as the hypertrophy is more 
considerable." Dr. Stokes speaks of augmented sounds in hypertrophy. 
Dr. Flint tells us that hypertrophy of the left ventricle tends to exaggerate 
the element of impulsion of the first sound so long as the muscular power 
of the heart remains unimpaired. We read, also, that in hypertrophy the 
element of impulsion is relatively more exaggerated than the valvular 
element, and that exaggeration of the tricuspid portion of the valvular 
element of the first sound, is regarded as evidence in some cases of hyper- 
trophy of the right ventricle. " Exaggerated intensity of the pulmonary 
second sound is highly significant of hypertrophy of this ventricle." The 
matters thus brought forward by our author are of interest and deserve 
further consideration. Further study of the heart-sounds in health and 
disease is needed to establish the truth of the impulse element of the first 
sound. And, in hypertrophy, whilst the impulse is often greater, it is 
sometimes less than in health. It depends more on the nervous than on 
the muscular element. We find violent nervous palpitations where the 
moving power is inordinately excited, with no increased muscular develop- 
ment; and, at a certain stage of hypertrophy the heart moves slowly and 
feebly, and the impulse is less than in health. M. Beau has described what 
he calls asystole of the heart, as a sequel of valvular and of cavitary dis- 
ease. Under an obstructed circulation, the ventricles are hypertrophied 
and dilated, and thus the circulation is .carried on successfully for a while. 
The nervous power is, however, being used up, and presently fails. As 
long as it was sufficient, the signs of hypertrophy from strong and extended 
impulse are very marked. There may be loud murmurs indicative of ob- 
struction or insufficiency, but all disappear. The impulse and the sounds 
are feeble, there are no abnormal murmurs, the patient dies, and the post- 
mortem examination reveals an extent of cavitary and valvular disease, 
surprising those who had studied the case only during the last days or 

1 He says also in another place, whatever be the degree of alteration of the ven- 
tricles or auricles, there is no sensible modification of the heart-sounds as long as 
there is no disease of the valves. 



I860.] 



Flint, Diseases of the Heart. 



147 



weeks of life. Now, these facts should be borne in mind when we are 
called upon to prescribe for hypertrophy of the heart, and Dr. Flint very 
properly comments on mistakes which have been made in insisting unduly 
upon depleting and reducing remedies. Etiology should always go hand 
in hand with therapeutics. Hypertrophy is often a provision of nature 
consequent on valvular disease or on disease of the blood, and bloodletting 
and purgatives are not appropriate remedies in these classes of cases. Dr. 
Flint does not allude to the researches of Messieurs Menierie and Larcher, 
the results of which were confirmed by those of M. Ducrest, on pregnancy 
as a cause of hypertrophy. He thinks that in much the larger proportion 
of cases of hypertrophy, the anterior causative conditions are obvious, and 
are seated in the heart itself or in the large vessels. These antecedent 
pathological conditions being for the most part not removable, soberness 
and discretion should characterize the conduct of the practitioner. Small 
bleedings, laxative alteratives, have their place, and are not to be dispensed 
with altogether. Dr. Flint very properly says that muscular exercise 
within certain limits is to be encouraged, "that a certain amount of exercise 
is positively beneficial, by promoting the heart's vigour, and retarding the 
passage from predominant hypertrophy to predominant dilatation." If 
hypertrophy is regarded as a disease of nutrition, muscular exercise in the 
open air, so promotive of secretion, of excretion, and of all the processes of 
a healthy nutrition, is certainly to be recommended. 

The first chapter of Dr. Flint's book concludes with an article on en- 
largement by dilatation ; and the difference of the pathological processes 
involved in dilatation from those concerned in hypertrophy, is clearly 
pointed out ; hypertrophy being a consequence of over nutrition, and dila- 
tation the result of the yielding of the walls of the heart to a distending 
force. The second chapter is devoted to lesions, exclusive of enlargement, 
affecting the walls of the heart. Atrophy, fatty growth and degeneration, 
softening of the heart in typhus and typhoid fevers, and other affections, 
induration of the heart, rupture of the heart, cardiac aneurism, carcinoma, 
tuberculosis, have each their place assigned them, and in the account given 
reference is made to original researches on these subjects. We will pass to 
the third chapter, in which are considered lesions affecting the valves and 
orifices of the heart. Dr. Flint begins this chapter very well by saying — 

" Lesions of the valves or orifices of the heart are present in a very large pro- 
portion of the cases of organic disease of this organ, which come under the 
cognizance of the physician. In addition to the intrinsic interest which they 
possess as subjects for clinical study, they are important as standing in a causa- 
tive relation to other cardiac lesions, more especially enlargement of the heart, 
and also as giving rise to pathological effects, manifested in other parts of the 
body." 

We regret that "a full discussion of the origin and mode of production 
of valvular lesions, involving pathological points of much interest and 
importance," was inconsistent with the " practical objects" of Dr. Flint's 
work. He is very well qualified for this task, and the nicety of cardiac 
diagnosis is much dependent upon it. Dr. Stokes, in his work on the heart 
and aorta, says, "that, whilst we should by no means underrate the import- 
ance of differential diagnosis in valvular disease, the number of cases in 
which it is desirable to determine the exact seat and nature of the affection 
is comparatively small." This arises somewhat from the fact of the atten- 
tion of the patient not having been called to the disease in the earlier stages. 
An obstructive disease of the mitral valves is a more formidable affection 



148 



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[July 



than a similar affection of the semilunar valves of the aorta, and requiring 
a more careful regimen. The diagnosis is easily made. The facts, how- 
ever, that one lesion involves another ; that obstructive disease and insuffi- 
ciency of the same valves are often found together ; that there are 
murmurs and modifications of the heart-sounds where the valves are 
healthy ; and that sometimes, with extensive valvular disease, there are no 
murmurs at all ; that cavitary disease succeeds valvular ; and that the mo- 
tive power of the heart, its nervous system, is sometimes much disturbed, 
when there is neither valvular nor cavitary disease, and is irregularly affected 
by the same amount of lesion in exocardial or endocardial disease ; all 
these make diagnosis and prognosis difficult in cardiac affections, and render 
treatment uncertain. The relative frequency of mitral and aortic lesions is 
an interesting question ; and Dr. Flint tells us that in his own experience, 
of 104 cases, in 40 the lesions were mitral, and in 3T aortic. Mitral and 
aortic lesions coexisted in 14 cases, and in 4 cases only were there lesions 
of the tricuspid valves. In 61 cases of valvular lesions, rheumatism had 
occurred in 43 ; in 20 of 29 cases of mitral lesions, and in t of 14 of aortic. 
The rule that dilatation predominates in regurgitation without obstruction, 
and that hypertrophy is marked in obstruction without regurgitation, is 
sustained by an analysis of Dr. Flint's twenty-one cases, only three of which 
were exceptional. Prolongation of the interval between the heart's impulse 
and the pulsation of the radial artery, a symptom of aortic regurgitation 
pointed out by Dr. Henderson, was well marked in a case observed by Dr. 
Flint, where the interval between the apex-beat and that of the radial artery 
was longer than that between the first and second sounds of the heart, and 
the interval between the apex-beat and that of the carotid artery was the 
same as exists normally between the apex-beat and the radial pulse. 

The curious researches made by Dr. Upham, in the case of M. Groux, 
should be mentioned in this connection. They are found in the fourth 
volume of extracts from the records of the Boston Society for Medical Im- 
provement. Dr. Flint alludes to the application of the sphygmoscope, de- 
vised by Dr. Scott Alison, of London ; but its insufficiency to ascertain and 
measure the interval between the pulsation of the medio-sternal tumour in 
M. Groux' s case and the impulse between the fifth and sixth ribs, led Dr. 
Upham to devise means of appealing to the ear, which organ is more capa- 
ble of appreciating and measuring short intervals. The apparatus in the 
city telegraph room belonging to the city fire alarm at Boston, and that in 
the observatory at Cambridge, were called into requisition. Mr. Farmer, 
the electrical engineer, and his assistant, Mr. Rogers, were collaborators 
with Dr. Upham, and in the latter experiments they were in Boston, whilst 
Mr. Stearns, the superintendent of the Boston fire alarm, with Mr. Ken- 
nard, recently of the St. Louis fire alarm office, were at the observatory in 
Cambridge. The medio-sternal and apex-beats were compared, and, the 
whole duration of the pulse-beat being set down as 1.000, the interval 
between that of the medio-sternal tumour and of the apex was ascertained 
to be .038, and to that of the radial artery at the wrist .235. Calculations 
were made as to the time in which the heart's impulse is transmitted to the 
carotids, the temporal arteries, and the abdominal aorta. These researches 
are not merely very curious, they are valuable. Take, for instance, the 
controversy which has existed as to the time of the murmur heard in 
obstructive disease of the auriculo-ventricular orifice. Some maintained 
that a diastolic murmur, located at the apex, was a pathognomonic symp- 
tom of this disease. Others maintained that the murmur was systolic ; 



I860.] 



Flint, Diseases of the Heart. 



149 



whilst a third class of observers maintained that this murmur was heard a 
little before the contraction of the ventricles, was presystolic, whilst that 
from insufficiency of the mitral valves was properly systolic. 

Monsieur Herard, in an interesting article, published in the Archives 
Generates de Medecine for the year 1853, undertook to prove that an 
obstructive disease of the auriculo-ventricular orifice might give rise to a 
systolic murmur, to a presystolic murmur, to a dyastolic murmur, and that 
in certain cases no murmur at all was heard. He relates one case observed 
very carefully by himself, and cites eleven other cases to establish the first 
point. M. Fauvel, in an article published also in the Archives Generates 
for the year 1843, had proved that obstructive disease of the left auriculo- 
ventricular orifice gives rise to a presystolic murmur, Messieurs Earth, 
Roger, and Gendrin, having previously called attention to the fact. Four 
cases with an autopsy, and four cases without autopsy, all original with 
the author, are related to establish the proposition that a diastolic murmur 
does sometimes accompany an obstruction of the left auriculo-ventricular 
orifice, and these are followed by nine cases from various authors in support 
of the same proposition. That the same disease is sometimes found after 
death, when no murmur has been heard during life, is disputed by no one. 
Now, in connecting these facts with accounts given of the heart's move- 
ments, it is shown that they are consistent with the descriptions given by 
Harvey and Haller, and adopted by Hope, Burdach, Beau, Barth and 
Roger, Muller, Berard, where the systole of the ventricles is said to follow 
immediately upon the contraction of the auricles. Thus, in the first period 
of the heart's movements, we have the auricular systole, the passage of 
blood from the auricle into the ventricle through the auriculo-ventricular 
orifice, ventricular systole, and passage of blood from the ventricle to the 
aorta through the auriculo-arterial orifice. Obstruction or insufficiency of 
the auriculo-ventricular orifice, obstruction of the auriculo-arterial orifice, 
may give rise to systolic murmurs. A presystolic murmur produced by the 
blood driven by the contraction of the auricle through a narrow orifice is 
especially characteristic of obstructive disease. But it cannot always be 
recognized as presystolic, on account of the rapidity of the movements, of 
the very short interval between the contraction of the auricle and that of 
the ventricle. M. Bouillaud described the pulsations of the medio-sternal 
tumour in M. Groux's case as isochronous with the pulsations of the carotid 
and subclavian arteries and the impulse of the heart ; and yet Dr. Upham 
has demonstrated that the interval between these different pulsations is 
perceptible, and has measured it. We have noticed, ourselves, different 
observers looking at the medio-sternal and apex pulsations of M. Groux, 
some calling them isochronous, and some pronouncing that one preceded 
the other. Thus, we find additional and important proof of the truth of 
Harvey's and Haller's descriptions from these recent researches of Dr. 
Upham, and we recognize their importance as applied to the diagnosis of 
valvular disease of the heart. The fact that a diastolic murmur is some- 
times produced by an auriculo-ventricular obstruction is in agreement with 
the old description of the heart's movements, of the ventricles gradually 
dilating during the interval of silence and repose, the blood flowing into 
them ; and is fatal to the account given by M. Beau, who speaks of these 
cavities remaining closed after their systole. 

Dr. Flint speaks of direct mitral currents, and of direct aortic currents, 
which are the normal blood-currents. Mitral regurgitant and aortic re- 
gurgitant are the abnormal blood-currents associated with valvular insuffi- 



150 



Reviews. 



[July 



ciency. We do not like the classification of direct mitral murmurs with 
the diastole; for though they may occur at that time, yet they are more 
frequently caused by the contraction of the auricle which follows the silence, 
and is rather to be considered as the first act of the systole. We do not find 
any reference made to Dr. Herard's article, which seems to us conclusive. 

Dr. Flint devotes a few pages to a consideration of the modifications of 
the heart-sounds in cases of valvular lesions. Prof. Skoda first pointed out 
intensification or reinforcement of the pulmonic second sound as a valuable 
sign of mitral obstruction or regurgitation. Dr. Flint says that — 

" Mitral lesions impair the mitral portion of the valvular element of the first 
or systolic sound, other things being equal, in proportion to the extent of injury 
of the mitral valve which the lesions have occasioned. To isolate the sound 
referable to the play of the mitral valve, the stethoscope is to be placed without 
the left nipple, at a distance sufficiently removed to eliminate the element of 
impulsion of the first sound. If the mitral valvular sound be abnormally feeble, 
or wanting, provided the heart acts with sufficient vigour, it shows considerable 
or great imperfection in the action of the valve ; and, conversely, if the sound 
preserve its normal intensity and quality, it may be inferred that, notwithstand- 
ing the existence of lesions, the valve is not as yet much damaged. A mitral 
regurgitant murmur, or a mitral direct murmur, either or both, coexist in both 
cases ; in the former case the murmur or murmurs may be feeble, and in the 
latter intense, the intensity of the murmur bearing no proportion to the gravity 
of the lesions. In cases in which the mitral valvular sound is notably impaired, 
or extinguished, owing to the extent of injury to the valve, the tricuspid valvular 
sound may generally be distinguished by applying the stethoscope at, or a little 
without, the inferior or right border of the heart." 

We here see how a careful study of the normal sounds of the heart over 
different parts of the chest leads to important results in the examination of 
disease, in enabling us to ascertain its character and amount. Dr. Flint's 
remarks on the treatment of valvular lesions are very good and practical, 
and at the same time quite full. We are glad to see a caution against 
talking too much to patients, or communicating to them a positive unfa- 
vourable prognosis. 

" Some practitioners, participating in the popular impression that unsoundness 
of the heart is a very serious matter, involving liability to sudden death at any 
moment, injudiciously communicate their opinions and their fears to their pa- 
tients. I have repeatedly met with instances in which persons have been so 
informed, much to the prejudice of their comfort, usefulness, and even to their 
prospects of preserving comfortable health for a long period. It should be borne 
in mind that lesions which give rise to murmurs are often innocuous, the danger 
being prospective and perhaps remote. And even when the lesions are of a 
nature to involve obstruction or regurgitation, and have led to considerable 
enlargement of the heart, life and comfortable health may be preserved for many 
years. Moreover, statistics show that sudden death occurs only in a small pro- 
portion of the cases of organic disease of the heart." 

We should have expected in this connection an allusion to the opinion 
that aortic insufficiency is the valvular lesion associated with sudden death. 

Dr. Flint's fifth chapter is on congenital misplacements, defects, and mal- 
formations of the heart. The subject of cyanosis reminds the reader of the 
premature death of Dr. Moreton Stille, whose monograph on that subject 
is so valuable a contribution to the annals of science. 1 Certain affections 
incidental to organic diseases of the heart are considered in the sixth chap- 
ter. Angina pectoris is dwelt upon at some length. It is a rare affection 
in Dr. Flint's experience, as well as that of others. He found it in seven 

1 See No. of this journal for July. 1844, p. 25 et seq. 



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Flint, Diseases of the Heart. 



151 



of one hundred and fifty cases of organic disease of the heart. He regards 
it as a neuropathic affection, incidental exclusively to organic affections of 
the heart, but it is not symptomatic of any one of the varied lesions to 
which the heart is subject. Reduplication of the heart- sounds is taken up 
in the last article of the chapter, and Dr. Flint is able to throw some light 
on this subject from his own researches. To Dr. Walshe's question, "How 
is the fact that the second sound may be continuously doubled at the base, 
and perfectly pure and single at the apex, explicable on the simple valvular 
theory of the second sound?" he returns an answer — in the fact that the 
pulmonic second sound is so weak as generally not to be transmissible to the 
apex. Dr. Flint does not find this symptom, indicative as it is of aberration 
of the heart's action, to be followed by serious consequences. In a case of 
reduplication of both sounds, the patient recovered, and remained perfectly 
well for several years, notwithstanding moderate hypertrophy, dying at 
length of a disease foreign to the heart. 

Inflammatory affections of the heart occupy the seventh chapter. Peri- 
carditis is spoken of as a rare disease, and it is often an obscure disease. 
Several pages are devoted by Dr. Flint to its physical signs. Dr. Gairdner, 
of Edinburgh, has lately written on this subject; and Dr. Flint's conclusions, 
though differently stated, are not materially different from those of the Edin- 
burgh professor. The latter is more distrustful of his ability to distinguish 
exocardial from endocardial sounds, and here he seems to us more correct, 
as also in expecting less aid from auscultation in the diagnosis of the disease. 
A case is reported, showing that pleural friction-sounds may be produced by 
the action of the heart, corresponding with those reported by Dr. Addison 
and others. In speaking of the cerebral symptoms, Dr. Flint relates three 
interesting cases, where the cerebral symptoms were so prominent as to hide 
the usual signs, and refers to those published by Dr. Burrows. The con- 
nection of pericarditis with disease of the kidney is spoken of as existing 
in three of nineteen cases, where there was no other appreciable cause. 
The disease of the kidney resulting in an impure blood is regarded as the 
cause of the disease of the pericardium. In the treatment of pericarditis, 
bloodletting and mercury are properly spoken of as remedies to be used 
sparingly and with discrimination. Several pages are devoted to pericardial 
adhesions, and reference is made to the researches of Dr. Gairdner and Mr. 
Kennedy. Endocarditis is regarded as important from its complication 
with rheumatism and Bright's disease, and the experiments of Dr. Richard- 
son are very properly referred to. 

A chapter is devoted to functional disorders, and the last and tenth 
chapter is occupied with diseases of the aorta. It is very true "that there 
are few problems in clinical medicine more important than that which calls 
for a decision as to the existence of a purely functional disorder of the heart 
or of an organic affection." The fact that functional disorder generally 
occasions, in a marked degree, anxiety and apprehension, is properly con- 
trasted with the indifference and apathy of the subjects of organic disease. 
Attention is also called to the clinical proof that changes of structure do 
not originate in disturbed action of the heart. M. Bouillaud seems to think 
that inflammatory affections are at the bottom of all valvular diseases. 
He does not believe in the effect of the emotions to produce cavitary or 
valvular disease. Sam Slick, the Yankee clockmaker, seems to be of the 
same opinion, as, he says, the only person he knew to die of a broken heart 
was a man who attempted to lift an anchor. There is less scepticism now, 
however, than there was a few years ago as to the effect of the emotions on 



152 



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[July 



processes of nutrition. Bread pills and placebos are being again regarded 
with more favour by scientific men. Undoubtedly, at one time, a more pro- 
minent place in cardiac etiology was assigned to the affections and passions 
than belonged to them. The influence of rheumatism, of gout, of Bright's 
disease, are known and recognized only within comparatively a few years. 
It is difficult to estimate properly the agency of grief — of the exciting or 
depressing passions — to originate not merely disorder, but disease, in the 
great organs of circulation and respiration. Hope and trust certainly are 
powerful agents in the treatment of disease, though we may not understand 
how they act. Whatever creates or develops them is particularly beneficial 
in the treatment both of organic and functional diseases of the heart. The 
condition of the nervous system certainly is the obscure point in cardiac 
pathology. The state of the blood, the nutrition of the organs of circula- 
tion, afford difficult problems. Notwithstanding the successful researches 
of modern pathologists, by which the condition of the muscles and valves 
of the heart may be ascertained, the state of the nerves and nervous centres 
is not recognizable by our means of exploration. Dr. Arnold, head master 
of Rugby, a man so well known, so highly esteemed — one whose life was 
deemed so important to his fellow-men — dies of disease of the heart, of 
which his medical attendant seems not to have been aware till summoned 
to his bedside to witness his death. A recent biographer of Lord Macaulay 
calls attention to his very sudden and unexpected death, and remarks on 
the uncertainty of the signs of disease of the heart, and on the mistakes 
made in prognosis. 

Dr. Flint chose a difficult subject for his researches, and has shown 
remarkable powers of observation and reflection, as well as great industry, 
in his treatment of it. His book must be considered the fullest and clearest 
practical treatise on those subjects, and should be in the hands of all prac- 
titioners and students. It is a credit to American medical literature. We 
have pointed out some things which we could have wished otherwise in the 
plan and arrangement of the work. A smaller book could have been made, 
and nothing of value in the volume omitted. The style is for the most 
part clear and simple. We must object, however, to a few words which 
seem favourites with our author, and which justify the criticism that medical 
men are not sufficiently careful in the use of language, are fond of coining 
new words which are unnecessary. The word diagnostician, several times 
repeated, is of this character, and far from euphonious. The work itself is 
addressed to practical men — to physicians, to medical students — and not to 
scientific dilettanti. Dr. Flint, however, like all men of real merit, is not 
ashamed to confess his deficiencies, and he has a higher appreciation of the 
difficulties and extent of his task, of the impediments in an active and busy 
life to successful literary effort, than would be consistent with a claim to 
have been perfectly successful in what he undertook to do, or to have 
exhausted his subject. We hope that we shall hear from him again, and 
we look forward for him to increasing reputation founded on increasing 
desert. Having both faculties, and facilities for observation in his connec- 
tion with hospitals and consulting practice, he is well fitted to report and 
arrange facts, and to analyze and deduce from them legitimate conclusions. 
We confess a decided preference for a work, all the statements of which are 
susceptible of verification from its own resources, and which may be com- 
pared with those of independent observers. A certain degree of exactness 
is possible in medicine, and is the more desirable because we are often 
obliged to receive assertions founded on impressions easily effaced or dis- 



I860.] 



El well, Malpractice arid Medical Evidence. 



153 



torted, and not susceptible of verification. Such works as those of M. 
Louis may not be popular, they may have few readers, but we believe that 
there are genuine students enough to value material for thought and reflec- 
tion, and to appreciate the author who furnishes them with the means of 
drawing their conclusions, and allows them the exercise of their own faculties. 
Are we not in our day in danger of being too much engrossed in attempts 
to prepare knowledge and present it so that it may be easily received, 
forgetful of the necessity of the faculties being trained and disciplined in 
these very attempts to acquire knowledge. But we can pursue this subject 
no further, and we should be sorry if in touching upon it we should seem 
to be casting any reproach upon our author, whilst our remarks are really 
directed to certain influences acting upon all whose avocation it is to teach 
by lectures or by books. Gr. C. S. 



Art. XV. — A Medico-Legal Treatise on Malpractice and Medical Evi- 
dence, comprising the Elements of Medical Jurisprudence. By John 
J. Elwell, M. D., Member of the Cleveland Bar. New York : John 
S. Toorhies, 1860. 8vo. pp. 588. 

History teaches that from the earliest period, the practitioner of the 
healing art has been held responsible to arbitrary power, or tribunals of 
justice, for errors in the treatment of disease. According to Strabo, the 
first efforts to cure the sick, among the most ancient nations, consisted in 
exposing them in public places, so that whoever passed by, and had been simi- 
larly affected, might give their advice to the sufferers. Subsequently arose 
the custom of requiring those who were cured, to go and record in the tem- 
ples the symptoms of their diseases, and the remedies which had benefited 
them. In Egypt the temples of Canopus and Yulcan, at Memphis, con- 
tained the principal registers, but according to the same historian, the 
Babylonians and Lusitanians had a similar custom. These registers were 
preserved with great care, but the people were allowed to consult them 
freely, and select such remedies as they chose. Thus was collected a great 
number of facts, based on observations. In time, however, the priests, 
who were charged with the study of these records, began to assume the 
exclusive practice of the art ; and it was through their labours that a medi- 
cal code was formed, which embraced the recorded experience of ages. As 
might be anticipated, this collection of medical facts became the standard of 
practice ; and the first instances which we have of the legal responsibilities 
of medical men are in their departure from these established rules. "For 
the physicians," says Diodorus, speaking of the customs of the ancient 
Egyptians, "have a public stipend, and make use of receipts prescribed by 
the law, made up by the ancient physicians ; and if they cannot cure the 
patient by them, they are never blamed ; but if they use other medicines, 
they are to suffer death, inasmuch as the lawmaker appointed such receipts 
for cure as were approved by the most learned doctors, such as by long 
experience had been found effectual." Aristotle, alluding to the same cus- 
tom, says, "Even in Egypt the physician was allowed to alter the mode of 
cure which the law prescribed to him, after the fourth day. But, if he did 
so sooner, he acted at his own peril." 



154 



Reviews. 



Egypt supplied Persia with her physicians, but here a very different 
standard of success was established. In the failure of the physician to 
cure his patient, his own life was sacrificed. Manes, it is recorded, was 
flayed alive because he failed to cure the king's son. 

In Greece the same custom of recording recipes in the temples prevailed 
as in Egypt, and from that source was derived their first medical code ; to 
this standard the physician had to conform his practice at his peril. Pre- 
cisely in the same manner is the Chinese physician to this day, held re- 
sponsible for any departure from the rules and remedies laid down in their 
medical works. 

Pliny, inveighing against the physicians of Rome, laments that there 
was no law or statute to punish them for their mistakes ; he declares that 
the physician was the only person whose act was not called in question 
even if he murdered a man. However lax the laws of Rome may have 
been at the tifne Pliny wrote, they were afterwards sufficiently stringent. 

In the history of all the more civilized nations of antiqtiity we can trace 
the idea that physicians should be held more responsible for errors in their 
business than any other class of men. This feeling was naturally the off- 
spring of the public confidence in the power of the physician to save the 
lives of the dying, and restore to health the sick. Any failure to accom- 
plish this object was attributed to a malicious intent, and was hence made 
a capital offence. 

Among most modern nations the civil responsibilities of physicians are 
defined by statutory provisions, more or less precise, according to the nature 
of the individual government, and its advancement in the arts and sciences 
of civilized life. In France, Great Britain, and the Germanic States, espe- 
cially, are the laws relating to the medical profession stringent, yet liberal 
in their provisions, tending, in most respects, while they check and punish 
abuses, to develop, foster, and advance true scientific medicine. We shall 
not pause here to consider the status of medicine in our own country ; it 
will suffice to add that, while it receives from government no protection or 
support, it is held more directly amenable to courts of law for its errors, 
whether real or alleged, than in any other country. 

But though the physician has thus been held responsible to legal tribu- 
nals for errors in the practice of his profession in nearly every nation and 
age of the world, this branch of medical jurisprudence has attracted but 
little attention from writers in this department. The earlier writers have, 
however, given the subject more attention than later authors. Paulus Zac- 
chius, whose great work, Questiones Medic o-Legales, ranks as the second 
work on medical jurisprudence, published in 1634 the sixth book of that 
collection of essays, the first section of which was entitled "De Medicorum 
Erroribus a Lege punibilibus." This section consists of thirteen ques- 
tions, which are discussed at length, and embrace many of the most interest- 
ing points which arise in the litigation of cases of alleged malpractice in 
our times. Subsequent writers, who have discussed the subject at all, have 
drawn largely upon Zacchius. Many German authors have devoted a chap- 
ter or more to the subject of medical malpractice, but no author has, that 
we are aware, made it the subject of a special treatise. The same is true of 
French writers on medical jurisprudence. 

English and American authors have hitherto entirely avoided the subject. 
Even the voluminous work of Beck, which may well rank as an encyclo- 
pedia of medico-legal facts, has neither chapter nor section on this branch 
of forensic medicine. When we consider the importance now attached to 



I860.] 



El well, Malpractice and Medical Evidence. 



155 



malpractice in medicine by our communities, the frequency with which such 
suits are prosecuted in our courts, and the ignorance of both the medical 
and legal professions on most of the questions which arise in these cases 
for discussion, we are surprised that authors on forensic medicine should 
have so carefully evaded the subject hitherto. 

The author of the work before us has endeavoured to supply this de- 
ficiency in our medico-legal literature by the preparation of a treatise 
designed especially to elucidate the general principles of law applicable to 
medical men, and establish their true legal responsibilities. The importance 
of this undertaking no one can doubt; such a work has become a necessity, 
and we are only surprised that industrious and intelligent labourers have 
not long ago entered a field so white for the harvest, and garnered its rich 
fruits. Let us be thankful that one reaper has entered, and now returns 
hence, bearing his sheaf. 

We learn from the preface that the author combines in one person a 
knowledge of law and medicine, and may therefore be considered by educa- 
tion eminently qualified for the authorship of a work on legal medicine. 
A medical man writing on medical jurisprudence is said to discuss legal 
principles too much ; and, vice versa, a lawyer writing on the same subject 
introduces too much medical matter. This fault arises from the anxiety of 
each to appear learned in, or to do justice to, that division of his subject of 
which he has the least actual knowledge. A proper balance of the medical 
and legal educational qualifications of an author, in legal medicine, would 
seem, therefore, to be indispensable to a judicious consideration of the ques- 
tions which arise for discussion in a twofold light. In the works of Paris 
and Fonblanque, and Wharton and Stille, we have this blending of the two 
professions, and, no one can doubt, with the happiest results. 

In the introduction, the author gives the general plan and scope of the 
work. The important question has long agitated the profession of this 
country, How shall medical men protect themselves from unjust prosecutions 
while in the legitimate pursuit of their calling ? This question has been 
variously answered, and individuals have resorted to widely different methods 
of securing this end. Written contracts between surgeon and patient are 
but cobwebs for security ; nor do the sympathy and earnest support of pro- 
fessional friends shield the victim in the hour of trial. Dr. Elwell says: — 

"The only effectual and permanent mode, it is believed, by which the evil can 
be reached, remedied, and guarded against, is by elevating the standard of medico- 
legal knowledge in the professions of law and medicine. It is not to be denied 
that members of the legal profession, with few exceptions, are imperfectly in- 
formed upon medical questions connected with law, though they may be well 
educated in law generally, and well informed on every other subject." — p. 9. 

The imperfect knowledge of members of the bar of medico-legal subjects 
is attributed to the bad arrangement and general character of the works 
upon medical jurisprudence, which ignore malpractice altogether. Chitty's 
Medical Jurisprudence is represented as an elaborate work on the several 
departments of medicine, and Beck's treatise as a vast storehouse of undi- 
gested facts. The ignorance of medical men of their responsibilities and 
liabilities is due to the same cause, viz., the imperfections of our works on 
medical jurisprudence, and the omission of the entire subject of malpractice. 
Hence the design of the work under examination. 

" The author has attempted in this volume to present the medico-legal ques- 
tions likely to engage most frequently the attention of attorneys and medical men, 
in a circumscribed and compact form, and to reduce, if possible, the voluminous 



156 



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[July 



literature of the subject, scattered throughout law and medicine, to a practical 
system ; with what success, others are the judges. 

"Proceeding upon the idea that much more matter of a strictly theoretical 
and medical character is connected with the discussion of medico-legal subjects, 
in most works upon medical jurisprudence, than is necessary, tending, as it does, 
to repel, rather than enlighten, the legal inquirer, and rendering his search use- 
lessly laborious, the author has endeavoured to strip the subject of all such 
profitless details and discussions, leaving the consideration of speculative themes 
to other works and writers. 

"It is also the aim of the present work to furnish to the medical man that 
necessary information respecting his legal responsibility as a practitioner and 
witness which he has been hitherto unable to obtain, except by the general study 
of law. In short, the author believes it possible for both of these classes to 
arrive at the desired point, and command the necessary information by a much 
shorter road than that usually taken, and at a much less expenditure of time."' 
—p. 12. 

Before leaving the Introduction, we must express our dissent from the 
views of Dr. Elwell, in regard to the proper remedy for the too frequent 
prosecutions to which medical men are subjected. Our own experience in 
suits for alleged malpractice, has led to the conclusion that both the source 
of the evil and the remedy lie within the pale of the profession itself. The 
secret history of the vast majority of those cases reveals the humiliating 
fact that they were instigated by medical men. The following views, which 
we have elsewhere expressed, convey our own convictions in regard to the 
remedy for this evil : One of the most serious difficulties in the trial of a 
suit for malpractice in this country, is the conflicting and often contradic- 
tory nature of the medical testimony. It is this that misleads both judge 
and jury, and in nine cases out of ten decides the case against the defendant. 
The very means on which the surgeon can alone rely for defence, the opin- 
ions of his professional brethren, become of little or no account in the hour . 
of trial ; and however fair his case may actually be, he must submit it to 
the mercy of an unsympathizing jury. The great point to be attained, 
therefore, to insure a fair trial, is to render the medical evidence consistent 
with itself. This is to be done, not by taking the individual opinion of 
any man, however eminent, as law, but by having the average experience 
of the profession, as a guide. At present the medical witness testifies 
without any fear of having his opinions questioned, except by opposing 
witnesses, with whom he stands on an equal footing before the court. If 
he is honest, his opinions may be based on such limited observations as to 
make them really of no value; but if he is dishonest, and, as is often the case, 
personally interested in the prosecution, there is no limit or check to the 
knavery which he may practice. 

It is obvious, therefore, that to correct this great evil, and make the 
medical evidence on which these medico-legal decisions depend, consistent 
with itself and reliable for a court to follow, it is essential to establish by 
indisputable facts, the average of medical experience and skill on all those 
points in surgical practice, made the subject of litigation. For the surgeon 
is required by law to practise his profession with only average skill and 
success. To such a collection of facts, and the principles deduced there- 
from, every medical witness would be compelled to conform his testimony, 
while the court would have a guide to estimate the value of all medical 
opinions, as authoritative as the statute itself. 1 

The work is divided into two parts. Part first, occupying less than half 

1 New York Journal of Medicine, Sept. 3853. 



I860.] 



El well, Malpractice and Medical Evidence. 



15? 



of the volume, is devoted to malpractice ; part second is on medical evi- 
dence, embracing also the subjects of insanity, poisoning, infanticide, rape, 
and the ordinary questions in medical jurisprudence. As the subjects of 
the first portion of the work are of great interest and practical importance 
to physicians, and are now for the first time brought before the profession 
in the form of a treatise, we shall devote our space principally to an analysis 
of its several sections. 

The subject of the first chapter on malpractice is The General Principles 
of Law applicable to Medical Men. It is stated as a leading proposition 
that the civil responsibilities of those whose employment demands special 
skill and knowledge in the transaction of business, are the same. The 
physician, lawyer, engineer, machinist, ship-builder, and broker, are amen- 
able to the same general principles of law. As to the nature of the contract 
which exists between the physician and patient, the author remarks : — 

" The nature of the contract between the physician and patient, and attorney 
and client, are alike ; neither class, without an express contract, is a warrantor 
or insurer. Certainly nothing unreasonable or oppressive should characterize 
the rule of law in its application to the conduct of the professional man, thus 
making a different rule from that applicable to other men. 

" The professional man does not agree or stipulate to carry the case through 
to a successful issue at all events, and notwithstanding all contingencies ; and 
he is not to be tried by the result. 

" If a man contracts to do a thing that is absolutely impossible at the time of 
making such contract, he is not bound thereby, because no man can be com- 
pelled to perform an impossibility. But a distinction is taken between a contract 
to do a thing which is accidentally impossible, and wherein the party engages 
to do something absolutely impossible ; for, in the former case, the contract is 
binding, notwithstanding it was beyond the power of the party to perform it, it 
being his own fault and folly that he did not expressly provide against those 
contingencies he should know might possibly transpire, and exempt himself 
from responsibility in certain events. In such a case, therefore, the performance 
is not excused by the occurrence of an inevitable accident, although it was not 
foreseen by, or within the control of the party. 

"The physician or surgeon may, undoubtedly, undertake by express contract 
to perform a cure absolutely. In a contract of this kind, the utmost diligence 
and skill will not excuse him, should the result be unfortunate ; because it was 
his own fault, or inexcusable ignorance, that so uncertain a result should have 
been guaranteed successful. The extent of the physician's or surgeon's liability 
under an express contract to cure, will depend upon the circumstances of the 
case. If he undertakes an absolute impossibility, the law will not hold him 
responsible for the full extent of the damage resulting to the patient by reason 
of the failure to cure. His responsibility extends to a forfeiture of all compen- 
sation for medicine and service. The impossibility of the undertaking excuses 
him in part. 

"Neither will a want of sufficient skill or knowledge to fulfil an express con- 
tract excuse its performance. A builder may agree to erect a house or a ship 
of a certain description, and he cannot afterwards excuse himself on the ground 
of his want of sufficient skill. In that case, the maxim of the civil law applies : 
spondet perittam artis — the person undertaking to do the work is bound to use a 
degree of skill and attention adequate to the performance of his undertaking ; 
that is, to do it according to the rules of the art. So. a surgeon may contract 
for the removal of a limb, the physician for the cure of a disease, or the lawyer 
for the foreclosure of a mortgage, and by that contract he becomes a guarantor 
of the result. It is his fault to undertake to do a thing beyond his strength, or 
for which he has not sufficient skill, or to employ bad workmen; imperitia culpce 
annumeratur — ignorance is like negligence, for which one is responsible." — p. 21. 

To present this matter of contract and of the general responsibilities of 
physicians in a judicial light, we will quote in this connection the decision 



158 



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[July 



of Judge Bell, of New Hampshire, as given on page 142, in the case of 
Leighton vs. Sargent : — 

"1. A physician or surgeon, without a special contract for that purpose, is 
never considered as warranting a cure. 

* ; 2. His contract, as implied in law, is that, 1. He possesses that reasonable 
degree of learning, skill, and experience, which is ordinarily possessed by others 
of his profession ; 2. That he will use reasonable and ordinary care and diligence 
in the treatment of the case committed to him ; 3. That he will use his best 
judgment in all cases of doubt as to the best course of treatment. 

"3. He is not responsible for want of success, unless it is proved to result 
from want of ordinary skill, or from want of ordinary care and attention. 

" 4. He is not presumed to engage for extraordinary skill, or for extraordinary 
diligence and care. 

" 5. He is not responsible for errors of judgment, or mere mistakes in matters 
of reasonable doubt and uncertainty." 

These doctrines are now well established, and have been reaffirmed by 
nearly every judicial tribunal before which these questions have come for 
adjudication. Dr. Elwell gives great latitude to that part of the implied 
contract which relates to ordinary skill. According to him, as the degree 
of skill which a physician or surgeon exercises depends upon the advan- 
tages which he has for acquiring practical knowledge, so the term " ordinary 
degree of skill" may vary in its signification in the same State or country. 
He says : — 

• ; There are many neighbourhoods, in the West especially, where medical aid 
is of difficult attainment; yet cases of disease and surgery are constantly occur- 
ring, and they must, of necessity, fall into the hands of those who have given the 
subject but little, if any, thought. Thus the inexperienced and the unlearned 
attend to the surgery in their way, or it is not attended to at all. In such a case, 
and under such circumstances, and for these reasons, the ordinary degree of skill 
required by law would be good common sense, or such knowledge as the operator 
had. joined with a good purpose to help the afflicted, even if such interference 
rendered the patient a cripple for life. This is the law in both England and this 
country. Even in England, it was said by Hullock, in the case of Tan Butchell. 
that ' many persons would be left to die if irregular surgeons were not allowed 
to practise.' In these cases, no more, of course, should be expected of the ope- 
rator than the exercise of his best skill and judgment, however limited that 
might be. 

•'In large cities and towns are always found surgeons and physicians of the 
greatest degree of skill and knowledge. Their pretensions are properly laro-e. 
They are to be held to a corresponding high degree of responsibility. They 
contract to do more than the ordinary physician, and they are paid a higher 
price for what they do ; consequently the contract is more difficult to fulfil. 

" In the smaller towns and country, those who practise medicine and surgery, 
though often possessing a thorough theoretical knowledge of the highest elements 
of the profession, do not enjoy so great opportunities of daily observations and 
practical operations ; where the elementary studies are brought into every-day 
use. as those have who reside in the metropolitan towns ; and, though just as 
well informed in the elements and literature of their profession, they should not 
be expected to exercise that high degree of skill and practical knowledge pos- 
sessed by those having greater facilities for performing and witnessing opera- 
tions, and who are, or may be, constantly observing the various accidents and 
forms of disease." — p. 22. 

We have always doubted the correctness of the opinions here advanced, 
although they have received, to a certain extent, judicial sanction. It would 
be manifestly dangerous for our courts to attempt to instruct juries in re- 
gard to the meaning of ordinary skill, varying the definition according to 
the advantages which each locality was siqjposed to afford the practitioner 



I860.] El well, Malpractice and Medical Evidence. 159 



for the acquisition of practical knowledge. Nor would it be just to do so, 
were it possible. Eor while it is true that the metropolitan practitioner 
has greater facilities for acquiring experience in his profession, yet it is 
equally true, that he has counteracting influences to contend with in the 
treatment of diseases which are unknown in the country, and which often 
more than compensate for his greater practical knowledge. Again, there 
are fixed rules of practice which give, under ordinary circumstances, certain 
well established results. In the hands of every practitioner of intelligence, 
certain surgical apparatus will give a predetermined cure. This in surgery 
would be considered an average result, and would prove ordinary skill, for 
the result determines the degree of skill. The professional responsibility 
of the surgeon, whether metropolitan or provincial, terminates with ob- 
taining that average success in his treatment, and here should terminate his 
civil responsibility. The fact that a medical man lives in the country, how- 
ever remotely from large towns, ought not, in our times when communica- 
tion is so rapid, and books and periodicals are abundant and cheap, to be 
pleaded as an excuse for ignorance of the rules which are generally recog- 
nized in the profession as governing the practice of medicine, or indeed, of 
the latest improvements. The following opinion of Judge Woodward, in 
the case of McCandless v. McWha, sets this matter in a clear light : — 

"'We have stated the rule to be reasonable skill and diligence, by which we 
mean such as thoroughly educated surgeons ordinarily employ. If more than 
this is expected, it must be expressly stipulated for ; but this much every patient 
has a right to demand in virtue of the implied contract which results from in- 
trusting his case to a person holding himself out to the world as qualified to 
practise this important profession. If a patient applies to a man of different 
occupation or employment for his assistance, who either does not exert his skill, 
or administers improper remedies to the best of his ability, such person is not 
liable in damages ; but if he applies to a surgeon, and he treats him improperly, 
he is liable to an action, even though he undertook gratis to attend the patient, 
because his situation implies skill in surgery. * * * 

" 'The physician or surgeon who assumes to exercise the healing art is bound 
to be up to the improvements of the day. The standard of ordinary skill is on 
the advance, and he who would not be found wanting must apply himself with 
all diligence to the most accredited sources of knowledge.' " 

Besides ordinary skill, the professional man contracts to exercise reason- 
able and ordinary care and diligence, and also his best judgment in the 
treatment of diseases. The author discusses these subjects with much clear- 
ness, and from the decisions of the best authorities deduces the rules which 
are now applicable in our courts. The following in regard to the duties of 
patients is worthy of record : — 

" If the patient does not follow the prescription and co-operate with the sur- 
geon, he cannot afterwards call the surgeon to an account for any unfortunate 
result that may attend the case. 

"In the case of McCandless v. McWha, the Supreme Court of Pennsylvania 
said : ' Nothing can be more clear than that it is the duty of the patient to 
co-operate with his professional adviser, and to conform to the necessary pre- 
scriptions ; but if he will not, or under the pressure of circumstances he cannot, 
his neglect is his own wrong or misfortune, for which he has no right to hold his 
surgeon responsible. No man may take advantage of his own wrong, or charge 
his misfortune to the account of another.' " 

While it is thus established that the patient should co-operate with the 
surgeon in the treatment of his disease, there is a limit or rather qualifica- 
tion to this co-operation, which we desire to see stated in this connection. 



160 



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[July 



We therefore quote from page 132, of Dr. Elwell's work, the following 
opinion given in the same case as that above : — 

" 'A patient is bound to submit to such treatment as Ms surgeon prescribes, 
provided the treatment be such as a surgeon of ordinary skill would adopt or 
sanction. But if it be painful, injurious, and unskilful, he is not bound to peril 
his health, and perhaps his life, by submission to it. It follows, that before the 
surgeon can shift the responsibility from himself to the patient, on the ground 
that the latter did not submit to the course recommended, it must be shown that 
the prescriptions were proper, and adapted to the end in view. It is incumbent 
on the surgeon to satisfy the jury on this point ; and, in doing so, he has the 
right to call to his aid the science and experience of his professional brethren. 
It will not do to cover his own want of skill by raising a mist out of the refrac- 
tory disposition of the patient.' " 

In the consideration of many of the subjects of this chapter, the author 
has closely followed the admirable charge of Judge Bell, in the case of 
Leighton v. Sargeant, frequently copying him and his well collated refer- 
ences without, we think, due acknowledgment. 

Law and medicine are proverbially uncertain, the former, because of the 
fluctuating opinions of courts, the latter, because of the inHerent elementary 
difficulties connected with the practice of medicine and surgery. In Chapter 
IT., the author endeavours to mitigate the errors of medical men, by point- 
ing out some of the chief obstacles with which they have to contend in the 
treatment of disease. 

They are such as arise from the subtile agencies of animal life, differences 
of temperament, hereditary and acquired predisposition to disease ; the de- 
bilitating influences of modes of living, trades, passions, and the like, most 
of which are readily suggested to the medical mind. 

We regard the subject of this chapter of the utmost importance, as tend- 
ing, if properly considered, to place before the lawyer the real and unavoid- 
able causes of failure on the part of the physician in the treatment of disease. 
Could the capable and conscientious legal adviser clearly understand and be 
thoroughly impressed with the inherent elementary difficulties in the prac- 
tice of medicine, he would be slow to counsel prosecutions of medical men ; 
and had the court the same knowledge, we believe that a nonsuit would be 
the summary termination of many a trial for alleged malpractice. It is 
upon these subjects that the legal profession is in sad want of information, 
and we turned to this chapter, in the belief that the medical education of 
the author would enable him to elucidate in precise and accurate terms, the 
true sources of failure in practical medicine of which the physician is himself 
so often painfully conscious. But we were disappointed. Although the 
general statements which it contains would suggest to the medical mind many 
of the difficulties with which he has to contend, there is wanting that spe- 
cific information which the non-medical reader requires, to appreciate pro- 
perly the reasons that with given modifications of internal or external condi- 
tions of the individual, the best efforts of the physician fail to accomplish 
a cure. Those well established principles should have been set forth in a 
manner to be readily comprehended by lawyers. 

Chapter III. consists of a brief consideration of the question : What 
definite knowledge is possible and essential for the physician and surgeon. 
The following proposition will interest the medical reader : ''The courts 
hold that the surgeon and physician must be master of that degree of know- 
ledge which is reasonably within their reach." The remainder of the sec- 
tion is written, as far as we can discover, without point, or purpose. The 
author lays great stress upon inflammation, and accordingly he asserts that 



I860.] 



El well, Malpractice and Medical Evidence. 



161 



the surgeon should have an accurate knowledge of this process. The im- 
portance of conservative surgery is illustrated, and the statement hazarded 
evidently on the authority of Mr. Skey, that the progress of surgery has 
been, and ever will be, characterized by a corresponding decrease of its 
operations, both in amount and severity. The truth is that the number 
and severity of operations increase with every advance of scientific surgery. 
The chapter closes with an appeal in behalf of the study of anatomy. Per- 
tinent to the inquiry of this chapter, we copy from page 55, the following, 
in regard to the knowledge which a practitioner of medicine should 
possess : — * 

" The standard of ordinary skill, which is required of every physician and sur- 
geon, it will be borne in mind, is that degree and amount of knowledge and 
science which the leading authorities have pronounced as the result of their re- 
searches and experience, up to the time, or within a reasonable time before the 
issue or question to be determined is made. It is not enough to plead that his 
treatment was that taught him by the ablest members of the profession and the 
best schools twenty-five years ago ; because, in a science that is advancing with 
the rapidity of medicine and surgery — that is, by observation and experience, 
yearly, and almost daily, correcting errors in practice, and abandoning hoary- 
headed theories, the fallacy of which has become apparent, upon which the 
practice has heretofore been based — that is, receiving auxiliary agencies from 
all the rapidly advancing sister sciences — there will be new facilities afforded in 
practice year by year, and errors constantly exploded. The authority, there- 
fore, that was at a previous day considered good, and upon which the court 
acted, may not, at this time, be admitted as the present standard of knowledge 
required of the physician and surgeon." 

"In no department of surgery has there been a greater change and advance- 
ment in treatment than in that of amputations. An amputation that would have 
been justified by the rules of surgery, and the operator protected in court, twenty- 
five years ago, or even within less time than that, would now be repudiated by 
the best authority, and the operator justly chargeable with ignorance and un- 
skilfulness." 

" Old physicians and surgeons cannot, therefore, rely with safety upon their 
elementary education, and what they may have learned in practice. It is abso- 
lutely important, for the protection of the patient as well as the surgeon, if he 
assumes the responsibility of performing an operation fraught with so great 
interest, that he should make use of every reasonable means of knowing w r hat is 
considered the best treatment at the time of the operation — not what would 
have been the proper course twenty years ago. A medical man cannot with any 
safety or propriety practise year after year without keeping himself informed as 
to the improvements of his science, especially if he practise surgery involving 
amputations, from which so many lawsuits result, and which are so fatal to the 
patient," 

Having thus passed in review in the three preceding chapters the general 
medical and legal questions connected with malpractice, the author enters 
upon the consideration of the special surgical accidents which give rise to such 
suits. They are Amputations, Fractures, Dislocations, Diseases of the Eye, 
and Incised Wounds. These subjects occupy the seven following chapters. 
It would occupy too much space to pass these several chapters in review, nor, 
indeed, would it be profitable to the medical reader for us to do so. We 
have already had occasion to notice an apparent want of familiarity, on the 
part of Dr. Elwell, with the medical aspect of the questions which have 
arisen for discussion. This defect becomes a serious fault in this portion of 
the work, which is principally occupied with medical questions. While the, 
legal rules and principles are stated with clearness and precision, the author 
betravs his weakness wdienever he touches a purely medical subject. 
No. LXX1X.— July 1860. 11 



162 



Reviews. 



The first sentence of the fourth chapter convinces us that the author has 
but superficially explored the field of malpractice, and hence can but indif- 
ferently appreciate the extent and importance of the work which he has so 
commendably undertaken. He asserts that " nine-tenths of all the cases 
of malpractice that come before the courts for adjudication, arise either 
from the treatment of amputations, fractures, or dislocations." 

According to accurate statistics to which we have access in several hundred 
suits for malpractice, but little over two-thirds were for the causes above 
assigned. Of 142 suits growing out of amputations, fractures, and dislo- 
cations, but 8 were referable to amputations, 32 to dislocations, and the 
remaining 102 to fractures. We allude to these statistics not to prove 
that the subject of amputation or dislocations occupy too much space in 
this work, but to show that there were many other causes of malpractice 
suits equally (and in many instances far more) entitled to consideration 
than these. The practice of obstetrics has given origin to a large number 
of suits for alleged malpractice, and the medico-legal questions thence aris- 
ing would be appropriate to the pages of such a work. 

It is quite true that the same general principles of law are applicable to 
all, but the medical questions involved, which require to be established upon 
a firm basis for the guidance of lawyers and courts, are innumerable and 
should be elucidated, and as far as possible established in a work that is 
designed to aid both professions in arriving at the truth on medico -legal 
subjects. 

I)r. Elwell quotes at length the opinion of Mr. Skey in regard to the 
various questions relating to amputations. The rules therein given are 
extremely judicious, and being clearly and yet concisely expressed, will be of 
great assistance to lawyers in determining the true issue of malpractice 
suits arising from this source. One adjudicated case is appended to the 
chapter. 

In the definition of the different forms of fracture, and in the explana- 
tions of their nature, the author becomes himself so confused as to be unin- 
telligible even to the medical reader. He speaks (page T9) of il com- 
pound and oblique simple fractures "a comminuted one involving great 
injury of the muscles, nerves, and bloodvessels ; and yet, the cuticle being 
unbroken, it must be technically called a simple fracture ; a compound 
fracture derives its chief importance from the greater extent of injury, as a 
general thing, to the soft parts of the limb ; consequently much greater dif- 
ficulty attends the healing process of the case ;" a compound fracture of the 
tibia, because the bone is superficial, and the wound of the soft parts slight, 
"may be, in fact, really one of the most simple; while, on the other 
hand, the most severe, troublesome and dangerous injuries may be, techni- 
cally simple, because the skin is not broken." It is not surprising that such 
explanations should give "rise to much confusion in the minds of those 
who have not given the subject much attention." The most common text 
book on surgery would, we think, have made this subject quite clear to the 
non-medical reader. 

The most valuable portion of the sections on fractures is the digest of 
Prof. Hamilton's Report on Deformities after Fractures, which is the 
subject of Chapter VI. 

Chapter VII. is devoted to the general consideration of dislocations, and 
though some of the difficulties with which the surgeon has to contend are 
correctly stated, yet we regret to find constant evidences of the author's lack 
of practical information on medical subjects, and an utter confusion of ideas 



I860.] 



El well, Malpractice and Medical Evidence. 



163 



when he ventures to discnss them. We quote from page 108-9 : " An igno- 
rant surgeon will sometimes apply the bandages around the elbow joint, to 
which he applies his extension in such a way that it slips, and defeats the 
whole proceeding, or he will bind the elbow to a right angle, in order to get 
an immovable joint, giving unnecessary pain, and throwing the whole extend- 
ing force on the forearm. This is an inexcusable error ; so, of the lower 
extremities, the same principles apply. Again, the extending force being 
applied to the elbow, instead of the wrist, the bone is, in fact, being drawn 
up by the pectoralis major and latissimus dorsi, while through the medium 
of the triceps extensor muscle, is being drawn down, from which, the whole 
object is to separate and dislodge the head of the humerus. Both the sca- 
pula and the pelvis should remain as far as possible dormant, when exten- 
sion is applied for the reduction of a dislocated femur or humerus." 

We confess our inability to comprehend the author's meaning, either 
from the text or the context. 

Several adjudicated cases are selected from English and American 
reports, and appended to this chapter, which are of great practical interest 
both to the lawyer and surgeon. 

Chapter X. is devoted to the report of a case of alleged malpractice, in 
ophthalmic medicine, which was tried in the District Court, Cuyahoga Co. , 
Ohio, at the October term, 1857. The disease seems to have been origin- 
ally conjunctivitis, but subsequently sclerotitis, corneitis, and iritis were 
developed ; the patient changed his physician several times, and recovered 
with impaired vision. He brought a suit against the physicians who first 
treated the eye. The questions which arose for the medical witnesses to 
determine were as to the correctness of the diagnosis, and the proper treat- 
ment of the several affections above mentioned. The depositions of Drs. 
Delafield and Wallace, of New York, and Drs. Dix and Williams, of Boston, 
were taken ; and Professors Delamater and Ackley, of Cleaveland, who saw 
the case during its progress, and advised the treatment pursued, were im- 
portant witnesses on the trial ; the case was finally decided in favour of 
the defendant, and is one of great interest, not only to the ophthalmic sur- 
geon, but to the general practitioner. 

Chapter XL contains the depositions of Professors Flint and Hamilton, 
of Buffalo, taken in a case of alleged malpractice in dressing an incised wound 
of the foot. The case never came to trial. 

Akin to the responsibilities of the medical man are those of the druggist, 
the consideration of which is taken up before the subject of criminal mal- 
practice is introduced. There is no class of persons in any community 
whose occupation more directly bears upon public health, than those engaged 
in retailing drugs. The druggist is a dealer in poisons ; he supplies his 
customers, not with what preserves life and promotes health, but with what 
is essentially destructive of both. The articles which he sells are not 
designed for those in health, but for those who are sick. The vendor of 
provisions deals in that which is essential to life and health — the real pabu- 
lum vitae ; but the apothecary traffics in non-essentials, in poisons. 

And yet no person is held less strictly accountable for the manner in 
which he conducts his business, than the apothecary. He may commence 
the retail of drugs without the slightest preliminary education ; he may 
adulterate the articles which he sells to any extent he wishes without de- 
tection, and he may sell poisons without a physician's prescription, even to 
a child. The evils of this system are seen in the daily details in public 
prints of suicides, homicides, murders, and accidental deaths by poisoning. 



164 



Reviews. 



[July 



The real criminal in these cases, the retailer of the poisons, always escapes 
detection, and generally even a censure. The remedy, however, for this 
great and growing evil is more easily suggested than applied. Stringent 
statutory provisions, establishing, first, the educational qualifications of 
druggists, and second, prohibiting the adulteration of drugs, and third, 
regulating their sale so that poisons should be dispensed only upon a phy- 
sician's prescription, might be suggested as the basis of reform. But even 
where these legislative provisions already exist, the unlimited and unlicensed 
sale of drugs is carried on without the slightest check. Necessary as 
legislation undoubtedly is to a proper regulation of the retail of drugs, we 
must look to the pharmaceutists as a profession for the true remedy. The 
reform must commence by the organization of societies, through which can 
be established a proper standard of education for druggists. The American 
Pharmaceutical Association, now in the ninth year of its existence, gives 
the most gratifying evidence of the success which is to attend their efforts 
at internal reformation. We look hopefully to this organization, which is 
evidently rapidly increasing in influence, for the correction of the abuses to 
which we have referred. 

In regard to the principles of law which apply to druggists, they are 
the same as those applicable to the vendor of provisions. But Dr. Elwell 
very pertinently adds : — 

"More care should be exercised by those who mix poisons for internal use 
than is needed by those who sell fruit, food, and the like. Bad wines, provisions, 
fruit, and meat can usually be at once detected by the senses ; while the character 
of medical substances and compounds is only discovered by the careful analysis 
of an experienced chemist." — p. 169. 

Two adjudicated cases are given, in the second of which the true respon- 
sibilities of the druggist are brought prominently forward. In this case 
the druggist negligently allowed cantharides to mix with some snakeroot 
and Peruvian bark which the plaintiff purchased and took as a tonic, and 
was thereby greatly injured. The following opinions of the court place in 
a proper light the duties and responsibilities of druggists : — 

" 'Now, if a man who sells fruits, wines, and provisions is bound, at his peril, 
that what he sells for the consumption of others shall be good and wholesome, 
it may be asked, emphatically, is there any sound reason why this conservative 
principle of law should not apply with equal, if not with greater, force to vendors 
of drugs from a drug-store, as from usage may be presumed, a great variety of 
vegetable and mineral substances of poisonous properties, which, if taken as 
medicines, will destroy health and life, and the appearances of which are known 
to but few, except they be chemists, druggists, or physicians ? The purchasers 
of wines and provisions, by sight, smell, and taste, may be able, without incurring 
any material injury, to detect their bad and unwholesome qualities ; but many 
are wholly unable, by the taste or appearance of many drugs, to distinguish 
those which are poisonous from those which are innoxious, so close is their 
resemblance to each other. Purchasers have, therefore, to trust the druggist. 
It is upon his skill and prudence they must rely. It is, therefore, incumbent 
upon him that he understand his business. It is his duty to know the property 
of his drugs, to be able to distinguish them from each other. It is his duty so 
to qualify himself, or to employ those that are so qualified to attend to the busi- 
ness of compounding and vending medicines and drugs, as that one drug may 
not be sold for another, and so that, when a prescription is presented to be made 
up, the proper medicine, and none other, be used in mixing and compounding it. 
As applicable to the owners of drug-stores, or persons engaged in vending drugs 
and medicines by retail, the legal maxim should be reversed. Instead of caveat 
emptor, it should be caveat vendor. That is to say, let him be certain that he 



I860.] 



El well, Malpractice and Medical Evidence. 



165 



does not sell to a purchaser or send to a patient one thing for another, as arsenic 
for calomel, cantharides for or mixed with snakeroot and Peruvian bark, or even 
one innocent drug, calculated to produce a certain effect, in place of another, 
sent for and designed to produce a different effect. If he does these things, he 
cannot escape civil responsibility upon the alleged pretext that it was an acci- 
dental or an innocent mistake ; that he had been very careful and particular, and 
had used extraordinary care and diligence in preparing and compounding the 
medicines as required, etc. Such excuses will not avail him ; and he will be 
liable, at the suit of the party injured, for damages at the discretion of the 
jury.' "-p. 192. 

The three following chapters are occupied with the subject of criminal 
malpractice. Here we have no longer the question of skill, diligence, and 
care, but of intent, rashness, or want of clue circumspection. The first 
authentic decision relating to criminal malpractice, by an English judge, 
was given by Sir Matthew Hale, who held that — 

'"If a physician gives a person a potion, without any intent of doing him any 
bodily harm, but with intent to cure or prevent a disease, but, contrary to the 
expectations of the physician, it kills him, this is no homicide ; and the like of a 
surgeon ; and I hold their opinion to be erroneous that think if it be no licensed 
surgeon or physician that occasions the mischance, then it is felony, for that he 
be not licensed according to the statutes. They are subject to the penalties in 
the statutes, but God forbid that any mischance of this kind should make any 
person not licensed guilty of murder or manslaughter.' " 

Blackstone and most subsequent authorities coincide fully with Hale, and 
although numerous instances have occurred where the prisoner has exhibited 
the most criminal ignorance, if malice could not be proven he has been 
acquitted of the charge of murder and manslaughter on the strength of this 
decision. In the case of Rex v. Williamson, it was proven that the pri- 
soner mistook the prolapsed uterus for the placenta, and forcibly lacerated 
it, and tore asunder the mesenteric artery, causing the patient's death, and 
yet the verdict was, Not guilty. For the court held that there was no evi- 
dence of want of attention on the part of the prisoner, and the fact that 
he had attended other women in confinement was taken as proof that 11 he 
must have had some degree of skill!" The first trial of the notorious 
charlatan, St. John Long, in 1830, shows the influence of this opinion still 
existing in the courts of England. On the secoud trial the court gave a 
more enlightened charge, as follows : — 

" ' I have no hesitation in saying, for your guidance, that if a man be guilty of 
gross negligence in attending to his patient after he has applied his remedy, or 
of gross rashness in the application of it, and death ensues in consequence, he 
will be liable to a conviction for manslaughter.' " 

In our own country, the leading case is that of Commonwealth vs. 
Thompson, which occurred in Massachusetts. The prisoner, a quack, gave 
his patient emetics of lobelia until death ensued. Although it was proven 
on the trial that the prisoner showed the most criminal ignorance and 
indifference, the court was guided by the opinion of Lord Hale, and the 
want of statutory provisions of the State allowed the culprit to escape 
conviction. 

The rule, as at present established, is, according to Dr. Elwell, thus stated 
by Boland, B., in the case of Bex v. Spiller : — 

" 'The law, as I am bound to lay it down, and I believe I lay it down as it has 
been agreed upon by the judges — for cases of this kind have occurred of late 
more frequently than in former times — is this : If any person, whether a regular 
or irregular medical man, professes to deal with life or health of his majesty's 



166 



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[July 



subjects, lie is bound to have competent skill to perform the task that he holds 
himself out to perform ; and he is bound to treat his patient with care, attention, 
and assiduity.' " 

In another case, Lord Lyndhurst, C. B., held : When proper medical as- 
sistance can be had, a person totally ignorant of the science of medicine, 
takes on himself to administer a violent and dangerous remedy to one 
labouring under disease, and death ensues in consequence of that dangerous 
remedy having been so administered, then he is guilty of manslaughter. 

These chapters on criminal malpractice, close with a case in which the 
prisoner violated the person of his patient under pretence of medical treat- 
ment. The case came before the highest criminal court of England, which 
held : " It has been suggested that were the act of the prisoner to be regarded 
in the light of medical treatment, it would be no offence. * * * The notion 
that a medical man might lawfully adopt such a course of treatment, is not 
to be tolerated in a court of justice." 

Part First concludes with a chapter on Abortion, in which the nature of 
the act, and its criminality, are briefly considered in connection with the 
leading American case, viz., The People v. Madame Restell. 

Having now passed in review that portion of the work which will es- 
pecially commend itself to the profession for its novelty as well as practical 
interest, we have reserved but little space for a notice of Part Second on 
Medical Evidence. We regret this less, because most of the subjects in 
this division are fully treated in other works on legal medicine. 

The chapters in Part Second, which will prove of the greatest interest 
to medical readers, are those which define the duties of medical witnesses. 
The chapters on Evidence in General, Experts, History and Importance of 
Medical Evidence, Duties and Responsibilities of Medical Witnesses, Privi- 
leged Communications, &c, include subjects upon which the medical pro- 
fession have little accurate information. Dr. Elwell has brought within a 
small compass, the rules that should guide the medical witness in courts, 
and has divested them of much of that extraneous matter which tends to 
confuse and mislead. 

The volume concludes with several chapters on the legal relations of in- 
sanity, on poisons as employed in the commission of crime, with brief sec- 
tions on infanticide, effects of wounds in producing death, rape, and coro- 
ners' office and inquests. 

In reviewing the work as a whole, our impressions of its general cha- 
racters may be briefly stated. We have alluded to some of the faults of 
the work in passing ; there are others of a serious nature. We refer to 
the style which is often very obscure and by no means free from grammati- 
cal inaccuracies. The arrangement of subjects also gives evidence on every 
page of haste or want of care in preparation. This is much to be regretted 
in a work that has been stereotyped. But overlooking these errors, it must 
ever redound to the honour of the author, that he has taken the initiatory 
step towards placing upon a proper foundation the civil responsibilities of 
medical men. Although he has not exhausted the subject, he has done 
much to establish the principles which are to lead to the development of 
malpractice in medicine as an important branch of medical jurisprudence. 

S. S. 



I860.] Todd, Lectures on Certain Acute Diseases. 167 



Art. XVI. — Clinical Lectures on Certain Acute Diseases. By Robert 
Bentley Todd, M. D., F. R. S., Author of "Lectures on Diseases of 
the Urinary Organs," &c. ; formerly Physician, now Consulting Phy- 
sician, to King's College Hospital, London. Philadelphia : Blanchard 
& Lea, 1860. 8vo., pp. 4T3. 

The two previous works of Dr. Todd, on "Affections of the Nervous 
System" and on " Diseases of the Urinary Organs, &c.," established for him 
in this country as well as in Great Britain, a high reputation as a Clinical 
Teacher. The volume now before us has an additional interest as being 
his latest work ; having been published but a short time before his lamented 
death. 

But, a stronger reason exists for considering this one of the most impor- 
tant medical books of the year. It is remarkable in its contents ; as ex- 
pounding and illustrating views of pathology and practice, not exactly ori- 
ginal or peculiar to the distinguished author, nor for the first time advanced 
by him in this book, but now most fully and emphatically stated, and dif- 
fering widely from those commonly accepted. Opposition, upon both the- 
oretical and clinical grounds, to what is commonly designated as the " an- 
tiphlogistic" treatment of inflammation, has been, for some years, especially 
associated with the names of Dietl and Skoda, and J. Hughes Bennett. 
But Dr. Todd, with similar views, if not a more rigid observer, was at least 
a more cautious reasoner, than either of his co-leaders in the "advanced" 
school, whether at Yienna or at Edinburgh. Whatever has fallen from his 
pen must be received with attention, and considered with the respect clue to 
known ability, and undoubted honesty of purpose. 

It has been, then, with the profoundest interest that we have read these 
Clinical Lectures, put forth as the final result and legacy of thirty years' 
experience, by one whose scientific training had been severe, his capacity ac- 
knowledged, and his opportunities ample. We rise from their perusal with 
the mind burdened with the portentous question " What is medical truth ?" 
and it is only upon reflection, after a second reading, that we see how the 
harmony of inductive medical science can be found to include even these 
seemingly discordant notes. 

Before discussing, however, the strongly marked peculiarities of the work, 
it will be right to give some analytical account of its subject-matter. It 
consists of fourteen Lectures, delivered in King's College Hospital, and 
illustrated by an account in detail of ninety-three cases. 

The first three Lectures are upon 11 Rheumatic fever." The view taken 
of the pathology of this disease by Dr. Todd, is that which is now universally 
adopted ; that it is " a fever sui generis, of which the articular affection 
and the other phenomena are but clinical features — attendant symptoms, 
which may or may not occupy a prominent position." The term "metas- 
tatic," as applied to the internal inflammations occurring during rheumatic 
fever, is objected to, as the internal often occur simultaneously with the 
external local affections ; the phrase "erratic tendency" being therefore pre- 
ferable, in the case of rheumatism as well as of gout. In the latter, how- 
ever, true metastasis does sometimes occur. The rheumatic attack is thus 
diagnostically described : — 

"All these symptoms — namely, the articular swellings, the high-coloured and 



168 



Reviews. 



loaded urine, the furred tongue, the tendency to heart affection — are present in 
all cases of rheumatic fever, nor can we regard a case as of this nature in which 
these symptoms do not exist." 

Allusion is made, briefly, to a form of disease described by some of the 
French writers as " puerperal acute rheumatism." 

" Not unfrequently, after the puerperal state, the patient exhibits all the 
symptoms of ordinary rheumatic fever ; the same profuse sweats, the swollen 
joints, the fever, the lithic urine. But in some cases the disease runs a more 
formidable course ; the joints, instead of getting better after a time, continue 
to get worse, till at last the cartilages ulcerate, pus is secreted in large quanti- 
ties, and fills the synovial membrane to distension ; the articular extremities of 
the bones are laid bare, and the rough osseous surfaces grate against each other 
when the limb is moved. At the same time deposits of pus form in the muscles, 
and in other parts, even in the eyes. It is, in fact, a form of puerperal fever, 
due to inflammation of some of the uterine veins ; this gives rise to the formation 
of pus, which, infecting the blood, excites articular and other inflammations in its 
passage through the circulation. Such cases throw light on the pathology of 
rheumatic fever, and show how a morbid matter, generated at one part of the 
circulation, and carried throughout it, may occasion serious disturbance in the 
local nutrition of the various parts through which it may be undergoing elimi- 
nation." 

The pathological definition of rheumatic fever given (p. 29) in the same 
lecture, is in accordance with the suggestion of the last paragraph. It is 
" a high state of febrile excitement, induced by the accumulation of a pecu- 
liar morbid product, or materies morbi, in the circulation ; and the other 
symptoms which accompany it are merely caused by certain local derange- 
ments and disturbances produced at those points where its elimination from 
the system is taking place. This materies morbi is the result of a vitiated 
state either of primary or secondary assimilation, or of both." As to the 
nature of this morbid material, Dr. Todd does not furnish us with any 
enlightenment. The hypothesis that it is lactic acid, is considered to be 
probable, although not established. 

The second and third lectures are chiefly occupied with the treatment of 
rheumatic fever. Seven different plans are reviewed ; viz., by free vene- 
section; by moderate bleeding and diaphoretics; by mercury; by colchicum 
and guaiacum ; by opium ; by bark or sulphate of quinine ; and by elimi- 
nation. 

The first of these plans, by large venesection, is emphatically denounced. 

The second meets with similar objections. Even the abstraction of mode- 
rate quantities of blood is considered by Dr. Todd to " 'predispose to peri- 
carditis and endocarditis," and to render the patient more liable to vio- 
lent and troublesome delirium. 

The mercurial treatment, carried to salivation, is very reasonably spoken 
of as "a remedy nearly as bad as the disease." It does not, moreover, at 
all guard the patient from pericarditis, endocarditis, pneumonia, pleuritis, 
or peritonitis. Dr. Todd has more than once seen pericardial inflamma- 
tion supervene while the patient ivas in a state of salivation ; a case of 
this kind (Case II.) having been narrated in the first lecture, It is re- 
marked, at the same time, that rheumatic patients sometimes exhibit a dis- 
tinct tolerance of mercury, and are with difficulty salivated. 

Colchicum is regarded by Dr. Todd, in common with Garrod and most 
others at the present time, as exerting no specific influence over rheuma- 
tism; and guaiacum is believed by him to have even less claim to the same 
repute. Yet, he adds, "both these medicines, when given in large doses, 



I860,] 



Todd, Lectures on Certain Acute Diseases. 



169 



purge, and in such doses I have no doubt they may do some good, by 
eliminating the morbid material through the alimentary canal." Such 
medication, however, endangers prostration and debility, and a tedious 
convalescence. 

The treatment of rheumatic fever by opium, revived by Dr. Corrigan, 
of Dublin, is spoken of with respect by Dr. Todd, although he does not 
recommend dependence upon it alone. A remarkable tolerance of opium 
is frequently exhibited; sixteen grains of opium, for instance, besides a 
grain of muriate of morphia, having been taken, without narcotism, in 
forty-eight hours, by a patient aged 23 years (Case I.). 

Of quininization in rheumatism, Dr. Todd speaks well only in cases 
" where the sweating is colliquative, and the urine copious and pale, with 
abundant precipitates of pale lithates." He objects to its use from the 
beginning, as it tends to check secretion, and so may favour the develop- 
ment of internal inflammations. 

The method of treatment which our author has adopted and recommended 
is called by him the treatment by elimination. The skin is the chief route 
by which the removal of the morbid matter is sought to be effected. 

" The indications are, to promote the action of the skin, the kidneys, and the 
bowels ; to use antacid remedies ; and to give large quantities of fluid for the free 
dilution of the materies morbi, and to supply the waste caused by the drainage 
from diaphoresis and diuresis. The best way to promote the action of the skin 
is by opium, especially if you combine it with nitre and ipecacuanha. 

" Our usual prescription is one grain of opium, one grain of ipecacuanha, and 
five grains of nitre, every two, three, or four hours, according to the urgency of 
the symptoms, and the need the patient has for opium." 

The alkali preferred by Dr. Todd is the bicarbonate of potassa, in scruple 
or half-drachm doses every three hours. As a purgative, the usual com- 
bination of magnesia and Epsom salts is approved. In local treatment, 
our author considers leeching to favour the erratic tendency, and therefore 
to be injurious. He advises cotton-wool, wrapped with oiled silk, and in 
many cases small blisters. 

During this treatment, good beef-tea is administered from the first, in 
small quantities, frequently through the day. "Often," says the author, 
"you will find it useful, and always when there is a tendency to delirium, 
to give stimulants, such as brandy or wine." 

In the third lecture the management of rheumatism is considered still 
more in detail. The following practical remarks are interesting: — 

" You need not be afraid to apply blisters in the early stages of the rheumatic 
inflammation of the joints. I believe the dread which some physicians have of 
applying blisters near inflamed parts — as near an inflamed lung, or pleura, or 
pericardium — is due to their having used blisters of too great a size." 

Attention is called, in respect to prognosis, to the fact that the mitral 
valve may be affected, either so as to produce or so as not to produce im- 
pairment of the function of the valve ; the former if the deposit be on the 
auricular, the latter if it be on the ventricular surface of the valvular 
curtains. In both cases you have a systolic bellows sound, and in both 
cases that sound is best heard at the apex of the heart. 

" How are you to distinguish the one from the other ? If the bellows sound 
be purely regurgitant, its position is strictly at the apex ; it becomes in a marked 
way faint as you proceed to the base of the heart, and it is distinctly audible 
beneath the left scapula ; and, in addition, the sign pointed out by Skoda exists, 
namely, a marked intensification of the second sound. If the bellows sound be 



no 



Reviews. 



[July 



not regurgitant, you hear it well up to the base of the heart ; you hear it only 
feebly, or not at all, at the left scapula, and there is no intensification of the 
second sound. I may add that in this latter case the heart's disturbance and 
the sufferings of the patient are in a marked manner less than in the former." 

The complication of delirium in rheumatic fever is compared by the 
author, in its general characters, to delirium tremens. In many instances it 
ushers in pericarditis, pleurisy, or pneumonia; frequently it occurs after 
one of these maladies has set in, and sometimes it is present without them, 
so as to exhibit no necessary connection with any internal inflammation. 
These remarks are important : — 

" Now, what is the nature of this delirium ? It used formerly to be viewed as 
a metastasis of rheumatism to the brain, and to be treated antiphlogistically. 
I have treated some cases in this way and on this hypothesis, and I have had 
the opportunity, in consequence, I believe, of this treatment, of examining the 
state of the contents of the cranium in a few such cases. I can therefore assure 
you that there is no more inflammation, either of the brain or its membranes, in 
these cases than in delirium tremens. The membranes are perfectly free from 
abnormal deposit, the pia mater is pale, and the gray matter of the convolutions 
remarkably so, and the subarachnoid fluid is increased in quantity. These signs 
indicate not only that the brain has been imperfectly supplied with blood during 
life, but that the vascular pressure upon it is less than it ought to be, and that, 
consequently, an increase of the subarachnoid fluid has taken place. * * ^* In 
cases of this kind the brain is feebly furnished with a blood, poisoned, poor in 
colouring matter, and abounding in water." 

Reference is made, at the same time, to the evidence adduced by Dr. 
George Burrows {On Disorders of the Cerebral Circulation), teaching us 
that whenever we meet with a case of delirium, especially of rheumatic 
delirium, we should diligently explore the region of the heart, and watch 
the condition of that organ carefully from day to day. Yet Dr. Todd has 
seen this delirium in persons of strongly-marked rheumatic or gouty diathe- 
sis, accompanied by all the signs of rheumatic fever — the sweats, the furred 
tongue, and the lithie urine—and not only without cardiac, but even without 
articular affection. He believes the rheumatic delirium to occur much more 
often after bleeding, or in weakly subjects, than in sthenic cases, or those 
of patients who have not been reduced by treatment. 

As to the management of this symptom, viewing it as a signal of distress, 
our author urges prompt and watchful support of the system. All evacu- 
ation, by sweating, purging, &c, must be arrested. Nourishment must be 
given frequently, in small quantities, of beef-tea, arrowroot, milk, and, he 
continues, "it will be always necessary to conjoin with this wine or brandy, 
or porter, also to be given in small and carefully adjusted quantities. If 
the patient be wakeful, sleep must be procured by the free administration of 
opium." 

In cases of rheumatic fever, with or without delirium, Dr. Todd calls 
attention, at the close of the same lecture, to a sign of importance, as 
indicating the propriety of more generous treatment, even although the 
articular affection still continue troublesome. It is the passage of pale 
urine, in good quantity, either without precipitate, or with a greater or 
less quantity of pale lithates. 

The fourth and fifth lectures are upon continued fever. Referring to 
the researches of Stewart, Jenner, and others, in Great Britain, America, 
and the continent of Europe, our author considers that it may be fairly 
admitted that there are three varieties of continued fever — the typhoid, 



I860.] Todd, Lectures on Certain Acute Diseases. 171 

typhus, and relapsing fever — each produced by a distinct, although doubt- 
less very similar, poison. 

The last of these forms, the relapsing fever, is merely mentioned, as 
being of comparatively rare occurrence. As a form of continued fever, 
our own observation and acquaintance with the medical literature of this 
country would incline us to ignore it altogether. Its adoption in classifica- 
tion by English writers appears to be chiefly due to the descriptions of Dr. 
Jenner; although Drs. Douglas, Murchison, Peacock, and others, also give 
accounts of it. 1 The history of its prevalence at Edinburgh in 1843 and 
1844, as recorded by Dr. Halliday Douglas (Northern Journal of Medi- 
cine), would, but for the non-rural nature of the locality, inevitably suggest 
a miasmatic origin. Upon the whole, although there is no question of the 
occasional occurrence of relapses after typhus as well as after typhoid fever, 
we are obliged to subscribe to the language of the editor of Dr. Bartlett's 
work, 2 who observes that "if there be a distinct febrile affection to be called 
relapsing fever, he believes that it has not been his fortune to see it." 

The first of Dr. Todd's two lectures on fever (Lecture IY.) contains the 
history of a fatal case of typhoid fever, with instructive remarks, especially 
upon the modes of termination of that disease. One of these, lost sight of 
by some observers, is "the absorption of a matter from the ulcerated surfaces 
of the bowel, which, circulating with the blood, exercises a poisonous and 
depressing influence on the system ; a matter of the nature of, if not iden- 
tical with, pus, which is absorbed, &c." This is illustrated by allusion to 
other forms of pyaemia, to which, however, a subsequent lecture is devoted. 

We pause only to quote a few characteristic expressions at the close of 
the fourth lecture, upon the subject of treatment. 

*' I wish to caution you against the morbid fear of over-stimulation, which leads 
many to adopt an opposite or a vacillating course, and to allow their patients to 
die from exhaustion. * * * I am convinced that it is much better to err on the 
side of over-stimulation than not to give enough ; for if we have over-stimulated 
a patient, it is very easy to pull him down again ; there are plenty of appliances 
and means for this purpose ; but if the patient sink too low, nothing is more 
difficult than to restore him." 

We are happy to find, however, on the same page with this carte blanche 
of stimulation, the candid testimony that, of continued fever, "the mild 
cases — and, fortunately, in many epidemics these are the most numerous — 
do perfectly well on a very moderate amount of nourishment, with little or 
no alcohol." 

Dr. Todd approves of the use of opium and astringents when, in typhoid 
fever, there is reason to fear that the bowels are ulcerated. He has no 
timidity, in such cases, as to the effects of inaction of the bowels, having 
never seen any bad consequence from their not acting even for four or six 
days. 

The pathology and clinical history of typhus and typhoid fever, and their 
complications, as illustrated by several interesting cases, form the subjects 
of the fifth lecture. Pneumonia, properly so called, our author believes to 
be an " extraordinary" complication of continued fever ; many cases, sup- 
posed to be such, having the character, even when fatal, of passive congestion, 
producing " carnification. " Similar congestion may also occur in the brain ; 
from toxaemic sluggishness of the circulation ; although Dr. Todd doubts 
the validity of the evidence relied upon in regard to this. He remarks that 

' See Bartlett on Fevers of the United States, p. 244. 
2 On Fevers, &c, p. 252. 



112 



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" much of the congestion of the brain observed after death is due to the 
mode of dying." Further : — 

" The subarachnoid effusions which we meet with now and then after fever are 
not of an active kind. They are the result of a certain shrinking of the brain, 
fluid being poured out to fill up space. Do not fall into the mistake of sup- 
posing that an effusion of this kind is instrumental in causing comatose symp- 
toms. It, in truth, exercises no more than the normal pressure which seems a 
necessary condition of the brain's nutrition." 

Dr. Todd uses, as local remedies for the coma of fever, blisters to the 
scalp or nucha, and the cold effusion or douche ; the latter being most 
applicable before great exhaustion has supervened. We cannot wonder 
that the good effect of such measures has been thought, by some practi- 
tioners, to justify a somewhat different view of the condition of the cerebral 
circulation from that taken by our author ; although we are fully convinced, 
that his opinion of the essentially toxasmic and non-inflammatory nature 
of the brain-symptoms in continued fever, as usually met with, is correct. 

The occurrence of a turn or crisis in fever, often with some kind of 
copious evacuation, is recognized, as observable in many cases, " at the end 
of the second or third week ; more commonly the latter." 

Erysipelas is the next topic considered, in the sixth and seventh lectures. 
The description of the general history of the disease, in Lect. VI., although 
full, need not detain us, except to note the statement, not, we think, equally 
familiar to all, that erysipelas very frequently begins in the throat; and 
to advert to the remarks upon the course and treatment of erysipelatous 
oedema glottidis. The latter is well spoken of as " one of the most formi- 
dable affections to which the human frame is liable." Dr. Todd's treatment 
for this, when the dyspnoea is great, is the prompt resort to tracheotomy. 

Two cases are narrated, in which this operation proved successful ; the 
recovery of the patients under such unfavourable circumstances being, in 
great measure, referred by Dr. Todd to their having been, after the operatiou, 
" well supplied with food and stimulants," in small doses at short intervals. 
Both of them were fed upon strong beef tea, with half an ounce of brandy 
every hour or two, besides quinine, ammonia, and chloric ether ; and, in 
one, quinine and beef-tea were also injected into the rectum. 

This, however, constitutes the mode of practice of Dr. Todd in all cases 
of erysipelatous disease. 

" The upshot of all I have to tell with respect to the treatment of erysipelas, 
is, to give stimulants and nourishing food freely, and from the very commence- 
ment of the attack. Don't trouble yourselves with too much attention to the 

secretions As soon as you are satisfied that the patient is labouring 

under erysipelas, at once begin to administer stimulants and nourishing food, 
using the precautions I have mentioned ; and what I wish above all things to 
impress upon you is, that this stimulating treatment should be employed from 
the very beginning of the attack." 

Alcohol is even considered, by Dr. Todd, as an antidote for the erysipe- 
latous poison. Tincture of sesquichloride of iron is looked upon, in 
comparison, as a trifling remedy. 

In examining the cases, seven in number, selected to illustrate this mode 
of treatment in King's College Hospital, we observe that only one is spoken 
of as " of good general health and temperate habits." Each of the others 
is deficient in one or the other respect; being noted as "intemperate," 
"hysterical," " greatly overworked," " having had fourteen children," or 
"past middle age, and, therefore, not the most favourable subject for 



I860.] Todd, Lectures on Certain Acute Diseases. 113 

acute disease." Now, this must be looked upon as important ; and it will 
probably be again alluded to hereafter, in our consideration of the general 
basis of Dr. Todd's therapeutics ; but, en passant, we must remark, that 
even erysipelas, to our view, presents ground for the distinction between 
' asthenic and sthenic cases. We are sure that we have seen scores of cases 
of erysipelas, many of them, too, in hospital practice, recover without one 
drop of alcohol ; and we cannot feel satisfied that, in all of these cases, 
half an ounce of brandy every hour or two would have been a safe addition 
to their treatment. 

Lecture YII. is occupied with "Erysipelas of the Fauces," "a form of 
inflammation believed to be erysipelatous, which, commencing in the throat, 
confines itself entirely to the faucial region." The affection is not a com- 
mon one, and, with the exception of Elliotson, appears to have escaped 
the notice of systematic writers. Its peculiarity consists in a sort of par- 
alysis of the pharynx. 

" If you look into the throat of a patient labouring under this affection, you 
will find the pharyngeal mucous membrane exhibiting a peculiar dusky-red 
colour, the fauces will be perfectly open, and you will be unable to discover any 
mechanical impediment to free deglutition ; and if, now, with your finger, or a 
pen or probe, you touch the back of the pharynx, you will find that none of the 
pharyngeal muscles are thrown into action, as they invariably are in a state of 
health ; in other words, you cannot excite the reflex actions necessary for de- 
glutition." 

The attempt to swallow either liquids or solids is attended by choking, 
and the sufferer is in danger of dying for want of food. Yery patient 
spoon-feeding, injection by the rectum, or the use of the stomach-pump, is 
often required. Alcoholic stimulation is strongly recommended in the 
treatment of this affection, with the local application of the solid nitrate of 
silver, or of a strong solution of it. Seven cases are related, of which four 
were fatal. 

The diagnosis of this form of sore throat from that of scarlet fever, is 
determined by the absence of the ulceration, and sloughing tendency of the 
latter; from that of diphtheritis, by the non-existence of the characteristic 
exudation ; from that of influenza, which it most resembles, by the greater 
swelling in the region of the tonsils, and the less lax and cedematous ap- 
pearance of the fauces and pharynx. 

Lecture Till, is "On the Treatment of Acute Internal Inflammations." 
This we will pass over for the present, as it may be most conveniently con- 
sidered in connection with the final lecture. 

"Pygemia" is discussed in Lecture IX. It is described as consisting in 
a poisoning of the blood by the admixture with it of 

"Either pus entire, and in its purest form, taken up directly into the circula- 
tion by an open vessel, or generated in some part of the vascular system ; or 
unhealthy pus — decomposing, acrid, septic — received in a similar manner; or 
some of the amorphous elements of such pus, received by reabsorption into the 
vessels ; or, some other animal matter, allied perhaps to pus, the product of 
disease during life, or of decomposition after death ; or, lastly, a peculiar animal 
poison derived from the recently dead human body, or that of some other animal. 
All these contaminations of the blood seem capable of giving rise to nearly the 
same train of general and local phenomena." 

These phenomena are briefly described, in connection with cases, as, 
rigors, fever of low type, utter prostration of strength, and the rapid suc- 
cessive formation of circumscribed purulent formations or deposits in the 
lungs, liver, serous or synovial sacs, muscles, or areolar tissue. The severity 



Reviews. 



[July 



of a case depends, according to our author, more on the quality than the 
quantity of the morbid matter taken up. This view is still more emphati- 
cally urged by Dr. J. H. Bennett, 1 who, with Boyer and Bonnet, supported 
by experiments of his own, believes that good pus produces, when introduced 
into the blood, no seriously detrimental effects. There is much reason, 
therefore, for the adoption of the term ichorsemia (Yirchow), or septi- 
cheemia (Yogel), instead of pysemia, as either of these terms indicates more 
clearly the contamination of the material necessary to produce the symp- 
toms of the so-called purulent infection. 

Dr. Todd, however, appears to have placed some confidence in the ex- 
periments of Gaspard and Cruveilhier, upon which the obstructive theory 
is founded. Pyaemia is referred, by him, as by most "others, in its origin, 
to suppurative phlebitis, in many cases ; in others, to surgical injuries of 
bones ; to the traumatic state of the uterus after child-birth ; to erysipelas, 
with subcutaneous suppuration ; to ulcerative absorption in typhoid fever ; 
and to dissecting or other poisoned wounds. The cases given in illustration 
of the history of these different forms of the disorder are interesting and 
instructive. The treatment advised is summed up in one word, support. 
"We are," adds the author, by our present knowledge of pyaemia, " prac- 
tically cautioned against the fashion (now happily becoming extinct), of 
giving depressing medicines to puerperal women; and the same remarks 
will apply to the treatment of severe surgical operations, and of injuries." 

The tenth, eleventh, twelfth, and thirteenth lectures, are upon 11 pneu- 
monia and its complications.'' 1 Simple pneumonia is considered by Dr. 
Todd as rare ; pleurisy (pleuro-pneumonia) being in nearly every case co- 
existent with it, to a greater or less extent. Further, we may have pneu- 
monia complicated with acute gout, or with rheumatic fever ; with tuber- 
cles ; or, sometimes, in the absence of tubercular deposit, with the strumous 
diathesis; besides typhoid, and traumatic pneumonia. Lobular pneumonia, 
spoken of as occurring in young children, associated with bronchitis or 
hooping-cough, is not recognized by our author; his belief being that the 
condition so described is really one of carnification, due to the exhaustion 
of the air from parts of the lung by excessive expiratory efforts. 

It is unnecessary to dwell long upon Dr. Todd's exposition of the gene- 
rally admitted facts in the history and diagnosis of pneumonia. In regard 
to the distinction between it and pleurisy with effusion, by physical explora- 
tion, the sign of segophony is mentioned, without any allusion to the strong 
reasons adduced by Skoda for doubting its validity as a pathognomonic 
sign. Very interesting observations are given, in the twelfth and thirteenth 
lectures, illustrated by tabular records, upon the disappearance of chloride 
of sodium from the urine during the hepatization of pneumonia, as shown 
first by Kedtenbacher ; and its abundance at the same time in the sputa, as 
afterwards ascertained by Dr. Beale. Examination was also made of the 
sputa, in one well marked case, to determine the presence or absence of 
grape-sugar ; but none was found to be present. The phenomena concern- 
ing the chloride of sodium appear to be of constant occurrence ; showing, 
as Dr. Todd remarks, that the disease involves profound changes in the 
chemistry of life — in the interchanges between the blood and the tissues, 
and in the chemical constitution of the blood itself. Dr. Todd states that — 

'■'When recovery takes place in this disease, there is always, I believe, some 
kind of critical evacuation, either by sweats, or by urine, or by the free discharge 



On Leucocytlitemia, 1S52 ; also, Lectures on Clinical Medicine. 



I860.] 



Todd, Lectures on Certain Acute Diseases. 



175 



of a purulent fluid from the bronchial tubes, or by pulmonary abscess. A criti- 
cal evacuation by the urine is by far the most common ; from the sixth to the 
tenth day this excretion being generally considerably increased, and having a 
tendency to deposit lateritious sediments. The critical evacuation next in order 
of frequency is that by sweating ; and if treatment were adopted to favour the 
secretion of the skin, this would be far more common, I believe, than has 
hitherto been observed." — p. 275. 

The subject of the treatment of pneumonia, as enunciated by Dr. Todcl, 
remains to be considered. Its principle is confessedly different from that 
supposed to have been attested by long experience, and, until of late, 
adopted as a part of universal belief. Let us describe it in the author's 
own words : — 

"It consists, not in the use of remedies directly antiphlogistic (so called), 
that is, of remedies intended directly to knock down inflammation by withdraw- 
ing blood, the supposed fuel of all inflammation, and by reducing vital power ; 
but in the employment of means which will promote the free exercise of certain 
excretory functions, by which the blood may be purified, and certain matters 
may be removed from the system, which, remaining in it, tend to keep up a state 
very favourable to inflammatory affections. The remedies to which I refer, tend 
to promote the free action of the skin and kidneys, and, in a less degree, that of 
the intestinal mucous membrane ; whilst, at the same time, a free stimulation is 
maintained of that part of the skin which is near the seat of pulmonary inflam- 
mation ; and an essential part of the treatment is, that while these remedies are 
being used, we do not aim at reducing the general powers of the system, but 
rather at upholding them by such frequent supplies of nourishment, easy of as- 
similation, as may be readily appropriated, and duly apportioned, both in quality 
and quantity, to supply the waste which, during the inflammatory process must 
necessarily take place in the most important tissues of the body, especially the 
muscular and nervous." — p. 199. 

Nor does Dr. Todd allow that this treatment is merely expectant; or 
trusting to the powers of nature alone. 

" I do not admit that the frequent application to the chest of such counter- 
irritants as mustard or turpentine (three or four times a day) and large doses 
of acetate or citrate of ammonia, and occasional purging, exercise no influence, 
either upon the whole system, or upon the local disorder." — p. 209. 

Tartar emetic receives but moderate favour from our author. He con- 
firms, however, the observation of Davies, Watson, and many others, that 
this drug acts best when it neither sickens nor purges the patient. 

Opium he considers not advisable in large doses in the simple forms of 
pneumonia, because it has some tendency to produce further congestion of 
the lungs and to depress the heart. 

Our idea of the management of pneumonia by Dr. Todd would still not be 
complete, without reference to one or two other passages. Thus, p. 265 : — 

" An important feature in this plan of treatment is to counteract, as far as 
possible, every influence of a depressing nature ; and though the exhibition of 
stimulants does not form a necessary part of it, still the aim should be to uphold 
the patient's strength." " When the vital powers are clearly depressed, with a 
pulse increasing in quickness, or when the patient has been previously accus- 
tomed to live well, or in the habit of indulging in the use of alcoholic drinks, 
then wine or brandy, or, what is really the proper way of expressing it, alcoholic 
food must be exhibited." 

The conditions alluded to in the last paragraph are important ; as, 
although rarely mentioned by the author in these lectures, they seem to 
have guided him in actual practice. Examining the history of the cases 
described in these four lectures, as treated by Dr. Todd, we find that, of the 



176 



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[July 



nine, five cases were treated without any alcoholic or other stimulant, 
although beef-tea and milk were given; one of these five, moreover, having 
been an intemperate person; while, of the four who took stimulus, one was 
noted as intemperate, one had been much exhausted by poisoning just 
before the attack, a third began with the use of wine only on the twelfth 
day, and the fourth with small doses (two teaspoonfuls every four hours) 
on the fifth day. This is, after all, not extraordinary practice for the wards 
of a city hospital. In one of the above cases, moreover, ten leeches were 
applied to the patient's side, on account of the obstinacy of the pain ; and 
in two, calomel was given in pill with opium ; although in one of these it 
was abruptly stopped, lest the rapid improvement occurring should be 
unjustly ascribed to the drug. 

Let us, however, inquire further into the theory of the author ; in the 
exposition of which we will find some expressions, more striking than any 
of those yet alluded to, in regard to the therapeutics of inflammatory disease, 
and the pathological and experimental basis upon which its treatment is 
founded. 

His view of the pathology of pneumonia is expressed by defining it as — 

" That condition of lung which leads to the formation of a plastic deposit in 
the cavities of the air-cells, which plastic material, by filling up the interior of 
these cells, and the finest bronchial tubes, consolidates the previously soft and 
crepitant pulmonary tissue." — p. 236. 

It is only after expanding this definition into a full description of the 
hepatized state, that it is added, that — 

"This state of red hepatization is, nevertheless, preceded by one in which 
the blood is delayed in that portion of lung about to become hepatized, and, 
very probably also attracted to it in increased quantity — a state, in fact, of what 
has been called active congestion ; in this consists the first stage of pneumonia."' 
—p. 237. 

Explanation of this 11 active congestion" is then attempted, by the intro- 
duction of irritating matter — "nervous derangement," ''increased action 
of the heart," "dilated and relaxed capillary walls," &c. It is really 
astonishing that those phenomena, most familiar and frequent of all in the 
domain of morbid processes, should still be, as they always have been, sub- 
jects of such various and often dogmatic controversy. Nor can we feel much 
less astonishment, that the most obvious and demonstrable of these pheno- 
mena should be, by physiologists and pathologists, at the present moment, 
systematically ignored, or, at least, depreciated far below their real import- 
ance. The active part taken by the arteries in the normal circulation of the 
blood, and the reflex excitement to which they are subject under morbid 
local disturbance, are overlooked, or denied, by almost all who have written, 
within the present decade, upon the physiology of the circulation, or the 
pathology of the inflammatory process. Baffled, and almost disgusted, with 
the vain hypotheses of the preceding periods, concerning "phlogosis," 
"congestion," "capillary spasm," &c, the most laborious students of 
nature have resolutely devoted their whole attention to the region opened, 
as a new field, by the use of the microscope. The phenomena of nutrition, 
of the interchange between the tissues and the blood, of the capillary forces, 
occupy them, to the exclusion of other facts, equally important, but lacking 
the fascination of recent development. Thus, in the works of Virchow, 
of Bennett, and of Todd, the very terms in ordinary use become transformed 
from their accustomed sense; "inflammation" means only "deranged nutri- 
tion," or "exudation," instead of including, as it always has done, and 



I860.] Todd, Lectures on Certain Acute Diseases. 111 

should do, these elements, with the intermediate one, as important as either, 
viz., hyperemia; active in the environs, and static at the centre, of the 
inflammatory process. 

We will not dwell upon this complicated subject, further than to express 
the regret, that therapeutical reasonings of such important practical bear- 
ing have been made to rest upon so fallacious, not to say distorted and im- 
perfect, a construction of the facts of physiological and pathological science. 
If we are to have a " revolution" in medicine, if, as we are told by Dr. 
Bennett, 1 we are now to await " the approaching downfall of empirical prac- 
tice," let us at least be warned by the fate of so many "provisional" estab- 
lishments, and look well to the platforms of those who would be leaders. 
Rather, let those who aim neither to lead nor to be led, save by "magis 
arnica Veritas, 11 calmly weigh all new facts, not forgetful of the old ; so 
that safe reform, when demanded, may be effected, without the agitation or 
the ultraism of innovation. 

Returning to the views set forth in the work under notice, we find (p. 
260) the statement, that a tendency exists, in most cases of pneumonia, 
towards improvement in the general and local symptoms, with sweating, 
free expectoration, &c.,from the eighth to the twelfth day. It is the rational 
purpose of the physician, then, to aid and promote this natural process of 
recovery, by eliminative measures, along with such as sustain the vital force. 
Dr. Todd knows of no treatment which will "cut short" pneumonia. If 
the term be applied by him only to the condition of actual exudation, it 
will certainly be necessary for all practitioners to agree with him ; only, 
with an appropriate change of phraseology, those of the "old school" 
must insist, that the timely use of local or general bloodletting may, some- 
times, in the forming stage of active congestion, prevent or mitigate pneu- 
monia, The importance of time in the treatment of pulmonary inflamma- 
tion, is recognized by Dr. Todd, in his quotation of the statistics of Grisolle. 
The cases narrated in the volume before us were none of them admitted into 
the hospital earlier than the third day ; several still later ; the time for act- 
ive depletion might, according to any school of modern practice, have 
then passed by. 

We must not omit referring to a passage in Lecture XIII. (p. 211), in 
which our author expresses a qualified assent to the occasional employment 
of bloodletting : — 

" If blood be taken, it should only be with the view of relieving pain, and for 
this purpose the application of a few leeches over the painful spot is the most 
successful plan; but when the dyspnoea is extreme, it is sometimes expedient to 
take a little blood from the arm. Those of you who are in the habit of attend- 
ing my hospital practice will bear witness how very rarely I have recourse to 
this proceeding." 

In another place (p. 250) he remarks that pleurisy exhibits, more than 
pneumonia, the characteristics of a (so-called) sthenic disease ; and that 
patients labouring under inflammation of the pleura, bear bleeding better 
than those who are suffering from inflammation of the lung. 

These expressions lead us to observe, first, that a wider difference exists 
between Dr. Todd and others, as, for instance, Alison, or Watson, or 
Wood, in theory than in practice, in regard to the treatment of inflamma- 
tion ; and, secondly, that so far as difference exists, it may find explanation, 

1 Clinical Lectures, Introduction, p. 18. 
No. LXXIX.— July 1860. 12 



178 



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[July 



to a certain extent at least, in the peculiarities or circumstances of experi- 
ence. 

On the first point, it may be said, that some errors of theory as to the 
rationale of antiphlogistic treatment, have undoubtedly prevailed. If it 
has been, as Dr. Todd asserts, a "notion, prevalent in the schools," that 
" certain acute and sthenic inflammations are attended with an undue exal- 
tation of the vital forces, both local and general, and that these must be 
reduced before the inflammation will yield," then it is certainly high time 
that such a notion should be corrected. For our own part, we are not 
aware of the existence of any form of disease whatever, in which it is a le- 
gitimate object of the physician to reduce, by treatment, the strength, or 
" vital forces" of the patient. But this does not prevent our occasional 
resort to the careful and moderate abstraction of blood, for the purpose of 
restoring the balance of the circulation in its disturbed states. And we 
believe it to be a mere imagination that the withdrawal of a few ounces 
of blood must necessarily, in all cases, make the patient weaker than 
he would otherwise become with the progress of his malady. There is no 
experience more certain than that, in cases of high sthenic inflammation, 
in the early stage, bloodletting promotes diaphoresis, diuresis, and the 
action of the bowels ; the very objects which Dr. Todd sets before us, in his 
eliminative treatment. 

In regard to the bearing of personal experience upon the opinions taught 
in this volume, it ought not to be forgotten, that its contents are based upon 
the clinical results of a hospital in a great city — the city of London. ~No 
doubt can exist that the peculiarities of local circumstance, atmosphere, 
food, and habit of the denizens of such a metropolis must affect, to a most 
important degree, the type, history, and therapeutical indications of their 
diseases. It is thus that, without assenting to all the theoretical views of 
our author, we can explain the fact that, in the course of a thirty years' 
experience, in and out of the hospital, but still in a London atmosphere, 
and chiefly upon London patients, he has, in pneumonia, "tried all ways — 
calomel and opium — bleeding — tartar emetic — and others which have been 
proposed," and has found that under each one of these a great number of 
deaths occurred ; or, even, that the number of deaths should seem to bereduced, 
when in his hospital practice, the administration of milk and beaf-tea, and 
occasionally alcohol, had been introduced. We use the term " occasionally," 
because, although the author's own expression is "in most cases I give wine 
or brandy early," we have seen that in those adduced in these lectures, for 
illustration, it was prescribed in less than half, and in them only under cir- 
cumstances of special exhaustion or previous intemperance. We are led, 
by these considerations, to the subject of the closing lecture of this volume 
(Lect. XIV.) Its caption is "On the therapeutical action of alcohol." 

The points dwelt upon in this lecture are, 1, the manner in which alcohol 
finds its way into the system, and the organs or textures on which its influ- 
ence is most directly exerted; 2, the "mechanism," so to speak, of its ac- 
tion on the body, and how it may operate as a poison ; 3, how far it may 
be used as a therapeutic agent, and the manner in which it may be employed 
as such, whether in acute or chronic diseases. 

Especial notice is taken, upon the first of these points, of the simplicity 
and rapidity of the process of appropriation of properly diluted alcohol, 
when ingested. This renders it eminently useful as food, when the digestive 
powers are impaired by disease. 

The principal influence of alcohol, when freely or poisonously taken, is 



I860.] 



Todd, Lectures on Certain Acute Diseases. 



179 



upon the nervous system. Generally speaking, Dr. Todd does not consider 
(p. 288) the symptoms referable to the digestive organs, to take a prominent 
place among those induced by it ; although we are somewhat at a loss to recon- 
cile this statement with one made in a subsequent place (p. 306), that "the 
signs upon which I recommend you to place your chief reliance, as indica- 
tive of the supply being too much, are mainly referable to the digestive 
organs. 1 '' 

Of the various unfavourable effects which alcohol is capable of producing, 
it behooves the practitioner (says our author) to observe that inflammation 
of internal organs is not one. Yet, in view of the fact, which he acknow- 
ledges, that strong alcohol, applied directly to any mucous membrane, will 
cause it to inflame, and of the vascular excitement, local and general, so 
familiar as one of its effects, it is not wonderful that it should have been 
supposed capable of inducing internal inflammations. Most probably, how- 
ever, Dr. Todd is right in his implication that, whatever part alcoholic ex- 
cess may take in the causation of cirrhosis or other organic degenerations, 
it is not by instigating inflammation of the organs involved. 

" I have never seen," says he (p. 290), " nor heard, nor read of any authentic 
case in which inflammation of the lungs, heart, liver, kidneys, bowels or brain was 
attributable to the ingestion of alcohol." " I think, then, we may discard the 
popular prejudice, that alcohol causes inflammation, and that therefore it ought 
not to be given in inflammation." 

A rational exposure is given of the ordinary fallacy, in regard to stimu- 
lation and "corresponding secondary depression ;" showing that it is only 
when inordinate or inappropriate quantities of alcohol have been taken, 
that any resulting depression follows exaltation. 

Carefully given, alcohol is considered by Dr. Todd to increase the animal 
temperature; to strengthen the action of the heart : and, under proper 
circumstances, to reduce the frequency of the pulse ; while it acts as an 
"aliment, appropriate to the direct nourishment of the nervous system, and 
to its preservation ; its special adaptation to this system giving it an im- 
mediate exciting power, superior to that of any other kind of food." "The 
popular notion that alcoholic stimulants are not food, but a mere 'flash in 
the pan,' ought not to be encouraged by medical men in the present day," 
(p. 116, note). It is very properly observed, however, that the successful 
use of alcohol in the treatment of disease depends very much on its mode 
of administration. It should be given in such doses as experience shows 
are assimilated with the greatest ease. 

" You should not order so much brandy or other spirit to be given daily ; 
but you should direct a certain quantity — say a teaspooonful or a tablespoon- 
ful — diluted with water, to be administered every half hour, every hour, or 
every two or three Jiours, according to the nature of the disease and the actual 
condition of the patient." 

One of the most important effects ascribed by the author to the " early 
administration of alcohol," in "all exhausting diseases, and in all acute 
maladies accompanied by high fever (p. 298)," is the prevention or mitiga- 
tion of delirium. 

" This fact as regards the influence of alcohol in the prevention of delirium, is 
one of the most important which the clinical observation of cases, treated by 
stimulants, brings out. It is quite inexplicable by those who refuse to study 
the action and the mode of digestion of alcohol, and who, adhering to old pre- 
judices, rest content with a practice under which, to say the least, great mor- 



180 



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[July 



tality occurs, rather than be at the trouble of carefully investigating the powers 
of an important remedial agent." Lect. VIII. p. 174. 

Flushing upon the first use of stimulants is not regarded by Dr. Todd 
as alarming ; it indicates difficult digestion, and maybe remedied by giving 
smaller quantities more frequently. Sometimes, lie asserts, flushing will 
occur from insufficiency of the dose, and an increased quantity will get rid 
of it ; just as an inadequate dose of opium disturbs the nervous system, 
wdiilst a larger one calms it (p. IT 6). 

Coma, as in fever, although it forbids the use of opium, does not, with 
our author, contraindicate the employment of alcohol. The excessive use 
of the latter, it is admitted, will produce a comatose state, often difficult to 
distinguish from that forming part of an acute morbid process. The main 
points of difference are stated as being, 1, that the coma of alcohol is not 
so profound as that of disease ; 2, that, if excited by alcohol, the omission 
of the stimulus for two or three hours will distinctly lessen the degree of 
stupor ; 3, the persistence of the fumes of alcohol in the breath is a sign 
that it has been administered in excess. 

We may sum up the teaching of this volume upon the subject now before 
us by extracting the following passages, from two different lectures (Lect. 
VIII. and XIV.) :— 

" Alcohol may be employed in all those diseases in which a tendency to de- 
pression exists ; and there are no acute diseases in which this lowering tendency 
is not present." — p. 293. 

" In a word, I cannot too strongly impress upon you that, to do good with 
stimulants, you must use them early, with care and watchfulness, in very definite 
quantities, and not in a vacillating or timid manner. They are agents of inestimable 
value for saving life under all forms of acute disease, and I can say with truth, 
from a large experience, that the harm which they do {in disease) is grossly and 
unfairly exaggerated, and always due to the slovenly administration of them. 
The opponents of their use argue from theiroutrageous abuse in health, against 
their careful and scientific use in disease I say it after mature re- 
flection and a long course of observation, that there is no point of therapeutics 
so deserving of the study of the earnest minded physician or surgeon, who is 
zealous to save life, as that of these agents, both in health and disease." — p. 176. 

This is striking language, especially as the passage last quoted terminates 
a lecture "On Acute Internal Inflammations." No recent work, with 
which we are acquainted, contains parallel views of therapeutics. They 
are not, however, entirely new ; exclusively of the preparatory dogmas of 
Dietl, Skoda, and Bennett, our own literature affords some resemblance to 
them, in a work published more than thirty years ago. In " Observations 
on the Autumnal Fevers of Savannah," 1 the author, Dr. Daniell, advocates 
boldly a principle of practice almost identical with that of Dr. Todd; 
treating even " determination to the brain" with stimulants, in a manner 
which very naturally struck horror into the minds of his contemporaries. 

We need hardly again allude to the position and authority of Dr. Todd, 
as interdicting the denial of his claim to be heard with attention, even in 
the assertion of doctrines still more strange than those contained in the 
book under review. Nor, to our mind, are the opinions to which we have 
last adverted, on the therapeutical action of alcohol, so essentially subver- 
sive of, or incompatible with, what we had been taught to consider sound 

1 Reviewed in the N. Am. Med. and Surg. Journ., vol. iii. 1827. Dr. Daniell, 
however, objected to ardent spirits ; preferring porter, claret, capsicum, and bark 
or quinine. 



I860.] 



Toynbee, Diseases of the Ear. 



181 



medical doctrine, as those previously alluded to, in these Lectures, upon the 
pathology of inflammation, and the scientific basis of its treatment. 

Upon the whole, to recommend this final work of Dr. Todd as a safe 
or appropriate guide to the inexperienced practitioner, is more than our 
judgment would suggest. But, on the other hand, it deserves the most 
attentive consideration of those whose matured experience and reason will 
permit them to "try all things, holding fast that which is good." As it 
is observed by the author in his preface, " it will not be affirmed by any 
one, that the doctrines of a science so abstruse and so difficult as pathology, 
should not be reviewed and reconsidered from time to time ;" and, as he 
also remarks, the real basis for all pathological as well as therapeutical 
inquiry, made with a full appreciation of the facts of normal physiology 
and morbid anatomy, is clinical research. H. H. 



Art. XVII. — The Diseases of the Ear; their Nature, Diagnosis, and 
Treatment. By Joseph Toynbee, F. R. S., Fellow of the Royal Col- 
lege of Surgeons of England, etc. etc. Philadelphia: Blanchard and 
Lea, 1860. 8vo. pp. 440. 

The work of Mr. Toynbee on Aural Surgery, which has been so long 
expected, and so long announced, has at length appeared. It lies before 
us, upon our table, fresh from the press of the American publishers. The 
latter have presented it to us in a dress, which leaves nothing to be desired. 
The author will have no reason' to complain of the appearance of the Amer- 
ican edition of his work, whatever may be its welcome by the American 
medical community. It is now our duty, as faithful journalists, not only 
to chronicle its advent, but to give some account of its contents. 

The neglect, with which diseases of the ear were formerly regarded, is 
fast passing away. Every year brings to us ample evidence of the truth of 
Mr. Wilde's remark in the introduction to his treatise on Aural Surgery, 
that, "notwithstanding the remarks which we hear daily in society, or 
which we meet with in the periodic and manual literature of the day — 
that the treatment of diseases of the ear is an opprobrium to medicine — 
the progress which this branch of medical science is making, is in all proba- 
bility as rapid as that in any other department of the healing art." The 
work, which contains this remark, was published in 1853, and is itself an 
admirable illustration of the truth of the author's statement. Mr. William 
Harvey, of London, published a book of very considerable merit, entitled 
the Ear in Health and Disease, in 1854. Mr. Harvey's book was followed 
in three years, by a bulky octavo volume of not less than six hundred and 
forty-four pages, on the same subject, from the pen of Mr. John Notting- 
ham, a Liverpool surgeon. Across the channel, and in the same year with 
the appearance of Mr. Nottingham's volume (that is, in 185?), E. H. Tri- 
quet, of Paris, presented to the public an elaborate treatise on diseases of 
the ear, which he dedicated to the memory of Itard, and to M. Bouillaud. 
In the meantime, English, French, German and American journals have 
contained a large number of observations and papers, from a variety of 
sources, on the anatomy and physiology of the auditory apparatus, and on 
its pathology and the treatment of its diseases. To all these works, which 



182 



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[July 



have so recently appeared, without adverting to the previous labours of 
Itard, Kramer, Lincke, Wolff, Schmalz, Martell-Frank, Hubert- Valleroux, 
Deleau and Meniere, we have now another, from Mr. Toynbee. Surely 
these are students, industrious and able, who are busy with the ear and its 
diseases. Thanks to their labours, the organ of hearing can no longer 
be regarded, as a terra incognita, and we may add that many of its affec- 
tions have been rescued by them from the opprobria medicorum. Mr. 
Toynbee has long been recognized as one of the most prominent and suc- 
cessful labourers in this department of science. His investigations have pro- 
bably done more to illustrate the pathology of the ear, than those of all 
other observers, whether English or Continental, and, therefore, we have 
looked forward to his treatise on the ear, which has just appeared, with 
unusual interest. The author states, in his preface, that it is the result of 
twenty years' labour. It would be strange, if it were not rich with new and 
valuable matter. 

The book is a large octavo, of four hundred and forty pages. The text 
is illustrated by one hundred engravings, most of which are illustrations of 
the anatomy or pathology of the ear. The author, in his treatment of his 
subject, has divided his work into nineteen chapters. Of these, the first is 
introductory, and the two last treat very briefly of the deaf and dumb, and 
of ear trumpets. What Mr. Toynbee has to say of the nature, diagnosis, 
and treatment of diseases of the ear is embraced, therefore, in the interven- 
ing sixteen chapters. One chapter he devotes to the external ear. He 
includes under this division only that portion which is external to the 
auditory meatus. To the external meatus, itself, he devotes five chapters. 
Two of these five contain an account of polypi, and of osseous tumours of 
the meatus. The membrana tympani, its anatomy, physiology, and dis- 
eases, are discussed in three chapters. One chapter embraces the Eustachian 
tube ; two, the affections of the cavity of the tympanum ; and one, those 
of the mastoid cells. What is usually called "nervous deafness," or dis- 
eases of the nervous apparatus of the ear, are disposed of in two chapters. 
In the remaining chapter we are presented with an account of malignant 
disease of the ear. 

Such is a brief statement of the contents of Mr. Toynbee's treatise. We 
should do equal injustice to it and to our readers, if we should not describe 
it more in detail, and yet our space forbids anything like a complete exa- 
mination or analysis of the work. Fortunately, it is not necessary for us 
to follow Mr. Toynbee, step by step, through his book, in order to present 
a sufficiently exact notion of what it is. In reality it consists of three dis- 
tinct parts. Of these, the first is concerned with the anatomy and physio- 
logy of the ear; the second, with its morbid anatomy; the last, with its 
pathology and its therapeutics. We do not mean that these three divisions 
are definitely laid down by our author, for we have just pointed out the 
order in which he has arranged and discussed his subject ; we only mean 
that everywhere, from the auricle to the labyrinth, he describes the anatomy 
and physiology of each part or tissue, in connection with its morbid ana- 
tomy, its diseases and their treatment. By this method, we are deprived 
of a separate and connected account of the anatomy and physiology of the 
organ he is dealing with, and occasionally there is some confusion of de- 
scription, which might have been avoided by a different division. But, on 
the whole, we are inclined to regard the method he has adopted as the best. 
It certainly possesses practical advantages, which are of great value. 

It is needless for us to speak of the excellence of Mr. Toynbee's anatomi- 



I860.] 



Toynbee, Diseases of the Ear. 



183 



cal descriptions. His previous papers have earned for him the reputation 
of being a most careful and accurate observer. His account of the mem- 
branous and osseous meatus, of the membrana tympani and its different 
layers of tissue, of the cavity of the tympanum with its chain of bones, of 
the osseous and fibro-cartilaginous portions of the Eustachian tube, of the 
mastoid cells and of the internal ear, we prefer to any other we have met 
with. As we have just intimated, these anatomical descriptions are detached 
from each other. They form a sort of introduction, or preface to the dif- 
ferent sections, wherein the morbid affections of different parts of the organ 
are discussed. His descriptions are always clearly given, and with as much 
brevity as the nature of the subject admits. Much of the ground which 
he goes over is old. It has been travelled over and described by earlier 
observers. But he has also been able to glean much that is new, and has 
given prominence to some minute points, which have been neglected or 
under-estimated. Yery little reference is made to other observers, and 
occasionally the inference might be drawn, by one unfamiliar with the sub- 
ject, that our author's descriptions are wholly novel. In one sense, we 
do not doubt they are ; they are evidently from Mr. Toynbee's own obser- 
vations and dissections, and not copied from others' labours. He is no 
copyist or compiler, but an original investigator. His physiological ob- 
servations on the functions of the membrana tympani, the cavity of the 
tympanum, the chain of bones, and other portions of the ear, are highly 
interesting and satisfactory. We do not suppose that physiologists will 
agree with him in all his views, though, for the most part, they will be 
regarded as correct. He maintains, for example, that "for the perfect 
performance of the function of hearing," the sonorous vibrations must be 
confined to the tympanic cavity. In other words, he regards the cavity of 
the tympanum as a shut cavity, the tympanic orifice of the Eustachian 
tube being generally closed. The observations by which he establishes 
this seem to us conclusive, though we believe it is not universally accepted. 

These portions of Mr. Toynbee's treatise, we refer to his anatomical and 
physiological descriptions, are highly interesting. Of themselves, they make 
a most important addition to our knowledge of the ear, and are the neces- 
sary basis of any just comprehension of its diseases, or of any rational treat- 
ment. Next to an exact knowledge of the anatomy and physiology of the 
ear, as a preparation for studying its diseases, comes a careful examination 
of its morbid conditions. The necessity of this is fully recognized by our 
author, who has presented us, in this volume, with a larger number of ob- 
servations of the morbid conditions of the ear, than are to be found in all 
other works on aural surgery put together. We are to recollect, however, 
with Mr. Wilde, that " morbid anatomy is one thing — pathology auother. 
The dead subject on the dissecting table teaches the student not disease, but 
the results of disease." It is of the utmost importance for us to know all 
the possible morbid changes of which the tissues of the ear are susceptible. 
Mr. Toynbee's work goes a great way towards completing our knowledge 
on this point. We cannot estimate too highly the value of his labours, in 
this direction, and we marvel at the patience and industry, which have 
enabled him to dissect two thousand ears or more. Only a portion of 
these dissections, however, are associated with the symptoms during life. 
Still a comparatively large number of observations are given, in which the 
history of the disease as well as the post-mortem appearances are recorded. 
This part of his work is its most valuable and original portion. We do 
not know of any treatise, in English, French, or German literature, where 



184 



Reviews. 



[July 



so much and such valuable matter, of the same kind, can be found. This 
renders his work invaluable. It makes it a mine of wealth, from which 
future observers will draw illustrations of their studies, and which no student 
can ever afford to ignore. We think Mr. Toynbee deserves the highest 
credit for the indefatigable industry with which he has prosecuted the 
studies, of which this volume contains the result and the record. 

What we have described as the third part of Mr. Toynbee's treatise, or 
its pathology and therapeutics, meaning thereby his description of aural 
diseases and their treatment, does not correspond in excellence with the 
rest. He describes disease like one who is more familiar with the ear on 
the dissecting table, than at the bedside, or in the consulting room. We 
should think that his clinical study of the ear was not so large or accurate 
as his observation of post-mortem appearances. We do not mean to apply 
this remark, by any means, to all of his descriptions of disease. Some of 
them are admirable illustrations of a complete and accurate account of an 
aural affection ; as for example, his description of acute and chronic inflam- 
mation of the dermal tissue of the meatus, whether confined to the meatus, 
or extending as it does, in rare instances, to the brain. 

In the chapter on polypi, three varieties of polypi are described; viz., 
the cellular, or raspberry polypus, the fibro -gelatinous polypus, and the 
globular polypus. This classification is a good one, and an excellent ac- 
count of the microscopic appearances of each variety is given, together with 
a clear statement of the condition of the tissues with which polypi are gene- 
rally associated. But no one would gather, from his chapter on these 
growths, any adequate notion of the obstinacy with which they yield to 
treatment, or of their tendency to return, when they have once been taken 
out, or in any way destroyed. Triquet is more explicit on this point. He 
states that in order to destroy a polypus, so as to prevent its return, it is 
necessary to continue an appropriate treatment for many months, and in 
one case he was obliged to persevere for two years. 1 Such is our own ex- 
perience. Sometimes they are readily and radically cured. More frequently, 
whether they are destroyed by potassa cum calce, or removed by the forceps, 
they obstinately persist in returning. Mr. Toynbee advances no such 
notion. On the contrary, the inference from his history of them is that 
they are readily amenable to treatment. 

Mr. Wilde, in his Aural Surgery, describes an affection of the ear, which 
he denominates exanthematous otitis. He invites the attention of practi- 
tioners to the condition of the ear, during and after scarlet fever and 
measles, and deprecates the neglect of the application of remedies " for a 
disease which is, even in the unhealthy condition in which the patient 
usually is at the moment, amenable to treatment " 3 M. Triquet, in the 
work just cited, devotes an important section to the discussion of the 
otitis which develops itself during the course of grave fevers, such as va- 
riola, scarlatina, typhoid fever. 3 That disease of the ear of some sort is 
apt to occur as one of the attendants, or as one of the sequelae of the exan- 
themata is notorious, and that its results are frequently injurious to the 
auditory apparatus is equally well known. Mr. Toynbee alludes to this 
matter, but he dismisses it with a degree of brevity that amounts to neglect. 
No directions whatever are given for any prophylactic or other management 
of the ear, at the time when it is attacked by an exanthematous disease. 
This omission is the more to be regretted, because the assistance of medical 

' Maladies de l'Oreille, p. 365. 2 Aural Surgery, p. 339, etc. 

3 Maladies de l'Oreille, p. 224, etc. 



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Toynbee, Diseases of the Ear. 



185 



art can be most efficiently and successfully invoked, when the ear is first 
attacked, and becanse general practitioners are apt to overlook the condition 
of the ear altogether at such times, their attention being engrossed by the 
constitutional affection. We regard this omission as a most serious defect 
in our author's work. 

A large portion of the tenth chapter is devoted to an account of the dis- 
covery, use and mode of application of the artificial membrana tympani. 
This is evidently a pet matter with Mr. Toynbee. It is probably well known 
to our readers, that the artificial membrane consists of a portion of vulcan- 
ized India-rubber, cut so as to fit nicely to the inner extremity of the 
meatus, and intended to render the tympanum an air-tight cavity, by co- 
vering the perforation which disease has produced. The results of this 
application are stated to be "more satisfactory than there was reason to 
anticipate." No unfavourable cases of its application are presented. The 
inference from Mr. Toynbee's language, with regard to his discovery, is 
that it is useful in nearly every case of perforation, and that it improves 
the hearing in a remarkable degree. We are sorry to say that our obser- 
vation does not bear out Mr. Toynbee's statements ; and we» think that 
whoever applies an artificial membrane, in exact accordance with his direc- 
tions, will be disappointed, both with regard to the degree of success and 
the number of cases in which it is applicable, if he founds his expectations 
upon the assertions of its discoverer. We do not say that an artificial mem- 
brane is never of use, that it is valueless. We have often applied it, and 
have often found a considerable benefit following its application, but there 
are many cases of perforation, in which it is of no use whatever; and many 
others, in which the advantage, obtained by wearing it is scarcely a com- 
pensation for the trouble of daily introducing it into the meatus. These 
cases are ignored in the work before us. An unfounded expectation is 
raised with regard to the value of the application. 

We think, moreover, that in general, sufficient stress is not laid upon the 
chronic character of certain affections of the ear, as well as on the incurable 
character of others. The inference from Mr. Toynbee's description of 
aural diseases, and the treatment he proposes for them, is almost inevitable, 
that, with the exception of some affections, which lead to disease of the 
cerebrum or cerebellum, and some others which reach into the internal ear, 
most derangements of the external meatus, of the membrana tympani, of 
the cavity of the tympanum and of the Eustachian tube, are not only sus- 
ceptible of relief, but of a speedy relief. Certainly this cannot be affirmed 
of diseases of the ear in this country. Possibly the climate of old England 
and the skill of its aurists, make a difference in favour of our trans-atlantic 
brethren, which, however, must be confined to England. On the continent 
no such immunity exists. 

We are glad to believe that the removal of tonsils for the relief of deaf- 
ness is not practised as much as formerly. Still we are inclined to think 
that it is too often done, and therefore we rejoice to find Mr. Toynbee ex- 
pressing himself emphatically against the operation, as a means of liberat- 
ing or freeing the Eustachian tube. He says : " On the supposition that 
the tonsil, when enlarged, pressed against and closed the faucial orifice of 
the Eustachian tube, the operation for excision, or partial excision of the 
tonsils has long been practised for the relief of deafness. Although, as 
already shown, the tonsil, however hypertrophied, cannot cause occlusion 
of the Eustachian tube, still the removal of a portion, in cases where it is 
much enlarged, is sometimes of service by diminishing the congestion of 



186 



Reviews. 



[July 



the mucous membrane at the orifice of the tube ; and it perhaps also 
operates beneficially by allowing the muscles of the tube to act more freely. 
This operation is, however, very rarely required ; and the best rule to follow 
is, never to excise a portion of the tonsil which appears to have important 
functions, independent of the fauces, unless it evidently interferes with the 
general health of the patient, or unless the obstruction of the Eustachian 
tube resists the other measures already indicated." — pp. 228-9. This is 
sound doctrine. 

There is no part of aural surgery of which we have had less knowledge ; 
none, of which the treatment has been more unsatisfactory or empirical 
than of that which has generally been called nervous deafness. Various 
theories have been advanced by which to explain its phenomena, and an 
equal variety of measures proposed for its relief, none of which were based 
on any accurate knowledge of the condition of the parts ; and none of 
which have been followed by any decided and permanent benefit. Mr. 
Toynbee's investigations have done a great deal towards rendering our 
knowledge more exact on this point. His dissections have revealed to us 
a variety of morbid changes in the ears of persons who died while afflicted 
with what was called nervous deafness ; and they have demonstrated the 
fact that organic lesions often accompany it. By a large series of cases, 
he has shown that alterations in the tissues of the cavity of the tympanum 
or of the ossicula, may induce impaired hearing, when the internal ear is 
free from disease. And he has also shown that the internal ear is suscep- 
tible of appreciable lesions, which impair or destroy its functions ; and that, 
sometimes, the nerve tissues themselves become diseased. In certain other 
eases, he found no morbid changes whatever, by which to account for deaf- 
ness. The importance of these and similar observations cannot be exagge- 
rated. They render our knowledge exact, where it was vague ; and lead 
to a treatment, or an abstinence from treatment, where all was unsatisfac- 
tory and empirical. The record of the investigations referred to, and the 
chapters in which the so-called nervous deafness is discussed, are among 
the most valuable portions of the work. No idle theories are set forth, or 
novel and useless modes of treatment proposed. And if the author has 
pointed out no means by which most of the affections of the internal ear 
can be relieved, he has accomplished the next most important thing, viz., 
to show why they cannot be relieved — to indicate the lesions which cause 
them, and which, in the present state of medical art, are incurable. 

In conclusion, let us express our high estimate of Mr. Toynbee's book. 
It is one which the student of diseases of the ear cannot afford to be with- 
out. If, in some parts, we have found it imperfect, its merits largely over- 
balance its deficiencies. It lays a foundation for aural surgery where its 
only just foundation can be laid, in a nice, exact, and honest study of the 
healthy and morbid states of the ear. It is concerned not with theories, 
but with facts. If its history of diseases is not as complete as we could 
wish, and its therapeutics not beyond criticism, it contains that sort of 
knowledge which the scalpel and microscope can alone reveal, and without 
which no history is of much avail, and no rational therapeutics possible. 
Whoever is thus occupied with laying the foundations of a science wisely 
and deep, and broad in the only way in which they can be laid, can afford 
to build the superstructure somewhat carelessly, leaving the niceties of 
building to other hands. We commend the book heartily to every student 
of diseases of the ear. E. H. C. 



I860.] 



187 



BIBLIOGRAPHICAL NOTICES. 

Art. XYIII. Reports of American Institutions for the Insane. 

1. Of the New York State Asylum, for 1859. 

2. Of the Bloomingdale Asylum, for 1859. 

3. Of the New York City Asylum, for 1859. 

4. Of the New Jersey State Hospital, for 1859. 

5. Of the United States Government Hospital, for the fiscal year 1858-9. 

6. Of the Kentucky Eastern Asylum, for the two fiscal years 1857-8 and 

1858-9. 

7. Of the Kentucky Western Asylum, for the two fiscal years 1857-8 and 

1858-9. 

1. From the report of the New York State Asylum, at Utica, it appears that 
the daily average number of patients at that institution, for the fiscal year ter- 
minating with the 30th of November, 1859, was 509, which is 36 greater than in 
any former year. " We have now," says Dr. Gray, " reached the fullest capacity 
of the buildings, and cannot expect, nor would it be wise, to extend the arrange- 
ments for more than the present number." 

Men. "Women. Total. 



Patients at the beginning of the year . . . 260 242 502 

Admitted in course of the year .... 170 142 312 

Whole number 430 384 814 

Discharged, including deaths .... 156 139 295 

Eemaining at the end of the year . . . 274 245 519 

Of those discharged, there were cured 72 42 114 

Not insane 3 3 

Died 21 14 35 



Causes of Death. — Exhaustion from mental disease, 9 ; general paralysis, 5 ; 
phthisis pulmonalis, 3 ; epilepsy, 2 ; dropsy, 2 ; abscess, 2 ; dysentery, 2 ; old 
age, general debility, pneumonia, injuries of head, measles, inflammation of hand 
and arm, gangrene of lungs, paralysis, typhoid fever, and cancer, 1 each. 

In one of the cases which proved fatal from phthisis, " hereditary predisposi- 
tion to insanity coexisted with the tubercular diathesis. The mental disease, 
while excited by the pulmonary affection, reacted with controlling effect upon 
the latter, arresting its progress, and undoubtedly prolonging the patient's life 
beyond the point which it would have attained had the pulmonary trouble alone 
existed." 

It is generally supposed that the paralysie ge'ne'rale of the French is almost 
invariably the consequence of luxurious or intemperate habits. For this reason 
we introduce the remarks upon the three cases in men which proved fatal in the 
course of the year : " In two of these, the natural course of the disease was 
interrupted by epileptiform convulsions. In one case, maniacal excitement 
followed sudden fright, general paralysis supervened, and an epileptiform seizure, 
six months afterwards, terminated fatally. In the other instance, the insanity 
was produced by loss of property, and resulted similarly at the end of two years. 
Both were characterized by maniacal excitement. The history of the third 
case failed to indicate the cause of the disease. Its duration was two years, 
and during the latter the patient was in this institution, in a condition of de- 
mentia. Before his death he lost, almost entirely, all muscular and co-ordinating 
power, and during the few last days of his life, the ability to swallow. The day 



188 



Bibliographical Notices. 



[July 



previous to death, consciousness seemed partially restored, and lie appeared to 
appreciate Ms situation. All these patients had been temperate and correct in 
their lives." 

Two women died of general paralysis. "In both, the mental disorder had 
existed about one and a half year, though the bodily health, in each, had pre- 
viously been greatly impaired. Both patients had suffered extreme and long- 
continued abuse from drunken husbands." 

" Of the 312 patients admitted, 31 were received for the second, 11 for the 
third, 4 for the fourth, and 2 for the fifth time." 

The following pertinent remarks relative to periodic and paroxysmal insanity 
contain some useful suggestions in regard to prophylactic measures, which are 
adapted to all persons having a predisposition to mental disorder, or who, from 
whatever cause, are threatened with it, 

"With increasing age and more frequent attacks, periodic mania is apt to 
become persistent, and the paroxysmal form of disease, which is a state of mild 
though permanent impairment not incapacitating the subject for most of the 
ordinary affairs of life, and characterized by irregular periods of excitement, is 
likely to degenerate into decided dementia. It is all important that such cases 
should, in their better states of health at home, avoid scenes calculated to pro- 
duce unusual exhilaration of spirits, and should refrain from nursing the sick, 
and from labours and exposures tending to lower the tone of health. Yet such 
advice, on their leaving the asylum, is needed but for a short time, as the pains 
and terrors of insanity, like those of other diseases, are obliterated from the 
memory by the enjoyment of returning health, and the pleasures and duties of 
home. Many persons, by a little care and sacrifice, by retiring early and thus 
securing a more than ordinary amount of sleep ; by absolute rest after any un- 
usual labour ; by avoiding protracted evening meetings of any kind, religious, 
social, or political, and by cultivating a quiet and equable temper, might be 
spared returns of disease, and ultimately that permanently disordered state of 
brain which, when reached, necessarily makes its subjects invalids, as all organic 
impairment must, and not only takes them from spheres of usefulness, but too 
frequently so transforms them that the normal relations and duties of life minis- 
ter to their discomfort and unhappiness rather than their enjoyment." 

The Association of Medical Superintendents of American Institutions for the 
Insane, have unanimously adopted a series of propositions in regard to the con- 
struction, of hospitals for the treatment of mental disorders. Among those 
propositions is the following: "The highest number (of patients) that can with 
propriety be treated in one building is two hundred and fifty, while two hundred 
is a preferable maximum." As has just been shown, the number at the Utica 
Asylum, at the close of the last official year, was five hundred and nineteen. 
But the establishment at Utica was erected not only before those propositions 
were agreed upon, but before the formation of the association mentioned. In 
the subjoined extract, Dr. Gray touches upon one of the arguments which should 
be primarily considered in an attempted estimate of the comparative merits of 
hospitals differing in extent, 

" Among the few unqualified advantages of a very large institution, is the 
necessity for organizing and keeping up all the ordinary trades and occupations. 
Under the care of experienced workmen, the patient may thus occupy himself 
in his accustomed manner, during a period of his convalescence, when unwonted 
labour would be distasteful, or call for so much mental effort as rather to injure 
than benefit him. The extensive farm and garden, besides giving ample employ- 
ment to the farming class, also require a large amount of unskilled labor, and 
furnish an agreeable diversity of occupation for all." 

When we consider the universally acknowledged utility of manual occupation 
in the curative treatment of insanity, this ability to carry on a variety of arts 
becomes a fact of no trivial importance, and it is not impossible that time will 
show that too little regard has been paid to it. 

Institutions for the insane, like most other things, have their individual cha- 
racteristics. Lectures are the forte of the Pennsylvania Hospital for the Insane, 
theatrical representations, of the Asylum at Utica. "Some years ago," says 
the report before us, " a platform was erected at the end of one of our convales- 



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American Insane Hospital Reports. 



189 



cent wards, and almost entirely by the labour and talent of the patients, a fine 
proscenium was placed upon it, stage machinery and properties adapted to it, 
scenery painted, and all the other necessaries for dramatic representations pre- 
pared. Each season a company is made up from the attendants and patients, 
and performances given with much success. This is now looked forward to with 
great interest by all. Much credit is due to several attendants and employees, 
who have taken the principal parts in the performances, with no inconsiderable 
labour and pains. During the past winter season, upwards of thirty entertain- 
ments were given. The stage was also occupied, at various times, by young 
ladies and gentlemen from the city, in private theatricals, and by several troupes 
of minstrels, vocalists, &c. The plays selected were mostly short and simple 
comedies, with which were given music, vocal and instrumental, tableaux, read- 
ings, and recitations." 

Patients admitted from January 16, 1843, to December 1, 1859 5,828 

Discharged recovered 2,340 

Not insane 42 

Died 671 

2. Short reports are, of late years, one of the characteristics of the Blooming- 
dale Asylum for the Insane. The one now under notice consists of twenty-two 
lines, in pretty large type, and two tables of statistics. 

Men. Women. Total. 



Patients in the asylum, January 1, 1859 
Admitted in the course of the year . 

Whole number 

Discharged, including deaths 
Eemaining December 31, 1859 . 
Of those discharged, there were cured 
Died 



63 


82 


145 


79 


59 


138 


142 


141 


283 


74 


57 


131 


68 


84 


152 


30 


25 


55 


9 


9 


18 



Twelve patients recorded as "improved" when they left the asylum, subse- 
quently recovered at home. 

Causes of Death. — Exhaustion from maniacal excitement, 7; apoplexy, 5; 
chronic disease of the brain, attended by partial paralysis, 2 ; general paralysis, 
pulmonary consumption, and pneumonia, 1 each. 

The daily average number of patients for the year was 152, which is larger 
than heretofore. 



3. The general operations of the New York City Lunatic Asylum, for the 
year 1859, are exhibited in the following schedule : — 



Men. 
269 
166 
435 
148 
287 



Women. 
386 
223 
609 
185 
424 



Total. 

655 
389 
1044 
333 
711 
148 
86 



Patients at the beginning of the year 
Admitted in course of the year . 

Whole number 

Discharged, including deaths 
Eemaining at the end of the year 
Of those discharged, there were cured 

Died 41 45 

Causes of Death. — Consumption, 26 ; paralysie g6nfrrale, 11 ; epilepsy, 7 ; 
congestion of brain, 7; old age, 6 ; typhomania, 6 ; apoplexy, 3; chronic diar- 
rhoea, 2 ; pneumonia, 2 ; exhaustion from mania, 2 ; erysipelas, fatty degeneration 
of the heart, submersion, tubercle of the brain, uraemia, diarrhoea, dysentery, 
paralysis, gangrene of the lungs, anaemia, disease of the heart, oedema of the 
brain, debility, and hydrocephalus, 1 each. 

The disease of two, reported among the recovered, was mania a potu. 
" Of those admitted within the year, sixteen had attempted suicide, one was 
under indictment for murder, and one for forgery, and one was detained as a 
witness. * * * Twenty per cent, of males and sixteen per cent, of females 
were readmitted, that is, had been discharged from the asylum some year pre- 
vious to 1859." 



190 



Bibliographical Notices. 



[July 



Of the 389 patients admitted, only 65 were born in the State of New York ; 
20 were natives of other States of the Union, and 304 were foreigners. 

"Amongst our patients," remarks Dr. Ranney, "poverty, with its attendant 
evils, is the most common cause of insanity. Want of wholesome nourishment, 
the breathing of an impure atmosphere, exposure to the inclemencies of the 
weather, the perplexities in obtaining a livelihood, all tend to favour the deve- 
lopment of disease. The tendency is increased when vice is connected with 
poverty, which, unfortunately, is too often the case. * - * * * From the 
middle classes of society, our number is much smaller. In the majority of these 
cases, all their energies had been devoted to business, with the purpose of ac- 
cumulating wealth in a short time. * * * Intellect meets intellect in com- 
petition, and if failure follow, disappointment acts as a strongly depressing cause 
on the already overtaxed mind." 

The American Institute, at the time of its last exhibition, "awarded a diploma 
to the inmates of the asylum for specimens of embroidery and silk quilt." 

Military drills and enthusiastic observance of holidays are among the charac- 
teristics of the New York City Lunatic Asylum. The past year has shown no 
falling off in these respects. 

The number of patients at this institution has become so large that the Board 
of Governors have determined to extend the accommodations by the erection of 
another building. 

4. The report for 1859 of the New Jersey State Lunatic Asylum, contains 
the following statistics : — 

Men. "Women. Total. 



Patients at the beginning of the year . . 148 145 293 

Admitted in course of the year .... 85 101 186 

Whole number .233 246 479 

Discharged, including deaths .... 92 81 173 

Remaining at the end of the year . . . 141 165 306 

Of those discharged, there were cured 44 32 76 

Died 17 9 26 

Admitted from May 15, 1848, to Dec. 31, 1859 . 745 818 1563 

Discharged recovered 292 313 605 

Not insane 1 1 

Died 108 98 206 



Causes of Death in 1859. — Exhaustion from chronic mental disorder, 13 ; 
exhaustion from acute mania, 4 ; epilepsy, 3 ; consumption, 2 ; apoplexy, con- 
gestion of brain, paralysis, and congestion of the lungs, 1 each. 

The whole number of patients in the course of the year was larger by fifty- 
three than in any preceding year. 

"Though the institution has been greatly overcrowded by inmates, yet the 
last may be fairly regarded as one of the most quietly prosperous years that has 
passed since its opening for the admission of patients. * * * A large pro- 
portion of the deaths have occurred in cases exhausted by such severe or long- 
continued bodily and mental disorder as to make death a welcome friend to 
relieve them from continued suffering." 

The report is mostly devoted to a description of the apparatus for a mechani- 
cal ventilation of the house, which has been introduced in the course of the past 
year. The fan, which is wholly of iron, is fifteen feet in diameter, and is fur- 
nished with eight wings or wind blades. 

5. The buildings of the Government Hospital for the Insane, are pretty ra- 
pidly progressing towards completion. At the elate of the report before us, it 
was expected that the centre and the three sections of wings, which were begun 
in the autumn of 1856, would be finished before the commencement of the now 
current year. The foundations of the four eastern sections of the eastern wing- 
were begun in April, 1859. The superstructure had been raised to the foot of 
the second story, and it was intended that the whole should be under roof by 
the 1st of January, 1860. 



I860.] 



American Insane Hospital Reports. 



191 



" The furniture of the centre and new wards is being, for the most part, man- 
ufactured upon the premises, and, to a considerable extent, from various hard 
woods grown upon the hospital grounds, as was contemplated when the appro- 
priation for the purpose was asked. Every exertion is being made to adapt the 
furnishing and fitting up, as well as the plan and construction of the house, to 
the various and peculiar habits of its deeply afflicted inmates, and to render all 
its apartments tasteful, comfortable and home-like. 

" The ventilation of the hospital is by a fan twelve feet in diameter, and having 
eight blades, each five feet long by three wide. It is propelled by a twenty-four 
horse power engine, of the most approved construction." 



Patients in the hospital July 1st, 1858 
Admitted in the course of the year 

Whole number 

Discharged, including deaths 
Remaining in the hospital June 30, 1859 
Of those discharged, there were cured 
Died 



Men. 


Women. 


Total. 


65 


52 


117 


47 


. 18 


65 


112 


70 


182 


28 


16 


44 


84 


54 


138 


16 


4 


20 


6 


4 


10 



Of the 112 men who were patients in the course of the year, 23 were from the 
army, 20 from the navy, and 69 from civil life. 

Causes of Death. — " Chronic, organic, and functional degeneration of the 
brain, irregular in character and extent, 5 ; the same, with chronic diarrhoea, 2 ; 
the same, with phthisis, 1 ; the same, with paralysis, 1 ; the same, with dys- 
entery, 1." 

The average duration of insanity, in the cases terminating fatally, was 5.4 years. 

Of the 257 persons treated since the Hospital was opened, 166 were born in 
the United States, 82 were foreigners, and the nativity of 9 was unknown. 

Of the 138 in the Hospital at the close of the year, 10 were independent or 
pay patients, and 128 were supported by the Federal Government. Thirty of 
the latter were from the army and the navy, and 98 were indigents, belonging 
to the District of Columbia. 

Dr. Nichols is devoting the best years of a vigorous and energetic life to the 
construction and management of this Hospital, the monument of a nation's phi- 
lanthropy and benevolence ; and we perceive with pleasure that his artistic skill 
and administrative talent are recognized by the general government, as is mani- 
fest from the following extract from the last report of the Secretary of the 
Interior : — 

"When all the buildings shall have been erected, the grounds inclosed, and 
the appointments completed, the institution will be a model of its kind, and, 
with a continuance of the successful management it has heretofore received, will 
be an honor to the government, and an inestimable blessing to that unfortunate 
class for whose benefit it was designed." 



6. The official year of the Kentucky Eastern Lunatic Asylum closes on the 
30th of September. Although the general report of its officers is published but 
once in two years, that of the physician is written annually, and two are printed 
together. 

Patients in the Asylum, October 1st, 1857 
Admitted in course of the first year . 
Admitted in course of the second year 
Whole number in the two years . 
Discharged and died in the first year . 
Discharged and died in the second year 
Remaining in the Asylum, Sept. 30, 1859 
Of the discharged, there were cured, first year . 
Of the discharged, there were cured, second year 

Not insane, second year 

Died, first year 

Died, second year . 



Men. 


Women. 


Total. 


129 


99 


228 


30 


27 


57 


32 


13 


45 


191 


139 


330 


32 


27 


59 


29 


14 


43 


130 


98 


228 


12 


11 


23 


13 


6 


19 


1 





1 


9 


11 


20 


4 


5 


9 



192 



Bibliographical Notices. 



[July 



Causes of Death, first year. — Acute mania, 1 ; paralysie generate, 2 ; exhaus- 
tion, 5 ; epilepsy, 3 ; phthisis, 6 ; chronic gastro-enteritis, 2 ; hemiplegia, 1. 
Second year. — Exhaustion, 4; phthisis, 3; typhoid fever, 1; marasmus, 1. 

44 No "one," says Dr. Chipley, "can observe the cases brought here without 
the conviction that a large number are sent to the asylum, not for medical treat- 
ment, but for the care required by old, feeble, and helpless imbeciles. This 
institution is thus rapidly becoming a mere asylum for incurables." Of the 57 
cases admitted in the first year, the disease of 43 had existed more than one 
year. ( 

An appropriation for improvements had been expended prior to the second 
year, and in the report for the latter term reference is made to the " greatly les- 
sened mortality as the highest evidence of the sanitary results of those improve- 
ments. The average annual mortality for the last sixteen years was 10.44 per 
cent,, or, excluding three years, in which epidemic cholera proved very fatal, it 
was 7.25 per cent., while the last twelve months gave a mortality of only 3.32 
per cent, The substitution of pure 'for impure water, the comfortable heating 
of the entire building, and the removal of the common sewer from beneath the 
floor of the basement to the outside of the building, could not fail to add to the 
comfort, improve the health, and diminish the mortality of the inmates of the 
institution." 

In reference to the patients discharged as cured, the author of the report says : 
" One had been in this institution over five years, and, up to the beginning of the 
present year, I never saw a case apparently more hopeless. He was discharged 
some months since, and remains quite well. - '' 

Upon the subject of intercourse between patients and their friends, Dr. Chip- 
ley writes as follows : — 

"I have known a single short interview with a relative to cause a relapse 
when the patient was rapidly recovering up to the time. It is known that very 
few insane persons recover who are detained at home, and it is remarked that 
patients from distant points are restored much more rapidly and certainly than 
those who are still near familiar scenes. The principle of association is strong 
in the human mind, and the bare sight of a relative may revive and strengthen 
the morbid chain of thought, when, by absence and proper treatment, it was 
about to be broken up forever. I do but express the opinion of all men of ex- 
perience when I say that the rule which forbids such intercourse should be 
enforced more stringently, rather than relaxed in any degree. While access to 
those who will not be injured by intercourse with their friends should not be 
denied, I feel that I would be derelict in duty if I did not choose to bear the 
reproaches of injudicious friends rather than to risk inflicting irreparable injury 
on my patients." 

Although he admits that insanity is increasing in a greater ratio than the 
total population, the doctor alleges, among others, the following argument to 
show that the increase is more apparent than real : — 

"Another cause for this apparent increase is due to the augmented longevity 
of the insane who enjoy the comforts of modern asylums. This is declared to 
be the fact elsewhere, and, I am happy to say, that statistics show it to be true 
in this institution. Thirty-five years ago, the average age of all who died here, 
for a period of four years, was less than thirty-seven years, while for the last 
four years the average was over forty-two years. Here is an absolute gain of 
five years in the duration of life, and it is obvious that an effect of it is to swell 
the number of living lunatics." 

The subjoined cases are interesting from their relation to medical jurispru- 
dence. 

" Several persons have been committed to the asylum accused of crimes sup- 
posed to have been perpetrated under the influence of insanity. Of this number 
was one reported in the foregoing table as ' not insane.' An inquest was held, 
the jury found the prisoner ' of unsound mind,' and the court very properly 
ordered him to be conveyed to the asylum. A single day's observation con- 
vinced me that he was malingering, and, after detaining him a sufficient length 
of time to confirm the opinion beyond all doubt, the prisoner was re-deliyered 
to the sheriff of the county where the felony is alleged to have been committed. 



I860.] 



American Insane Hospital Reports. 



193 



He is now in jail, awaiting his trial at the next term of the court. As one jury 
found this individual " of unsound mind," it is highly probable that, if he had 
been put upon trial for the crime charged against him, he would have been 
acquitted on the plea of insanity, and thus he would have escaped the just 
penalty of the law. 

" Since this report was made up. another person, acquitted of the crime of 
murder on the plea of insanity, has been committed to the asylum, and dis- 
charged therefrom on a writ of habeas corpus, after a detention here of only one 
week. I have reason to believe that this person never was of unsound mind, 
and that he escaped the rendition of a verdict on the merits of the charge, only 
by the vicious and imperfect method of investigating this plea. A fair and 
reasonable opportunity for examination by experts would probably have given 
a different result," 

After relating these cases, Dr. Chipley proceeds in a discussion of subjects 
connected with the medico-legal relations of insanity, and concludes by an ap- 
parent approval of the law in Maine, by which a person accused of crime, and 
in whose favour the plea of insanity is raised, may be placed, by order of court, 
under the care of the superintendent of the hospital for the insane, to be detained 
and observed until further order of the court. But the doctor would have ''two 
other intelligent persons associated with the superintendent in this commission, 
and their report should be made in writing, setting forth in full, for the con- 
sideration of the court and the jury, the reason why they believe the accused is 
or is not insane." 

It is recommended in the report that a distinct ward in one of the State 
asylums be appropriated to the insane criminals of Kentucky ; and the establish- 
ment of an institution for idiots is strongly urged. 

7. The report from the Kentucky Western Lunatic Asylum is biennial, but 
the statistics of the two years are, in part, reported separately. 

Men. Women. Total. 

Patients in the asylum, December 1, 1857 57 45 102 

Admitted in course of the first year ... 69 37 106 

" " second year . . 74 55 129 

Whole number in course of the two years . . 200 137 337 

Discharged and died in the first year ... 35 14 49 

" " second year 58 26 84 

Remaining in the asylum, December 1, 1859 . 107 97 204 

Discharged, cured, first year .... 21 6 27 

" " second year .... 27 11 38 

Died, first year 10 6 16 

" second year ...... 25 15 40 

The large mortality of the last year may be accounted for by the following 
gloomy account which Dr. Montgomery, who. if we mistake not, became con- 
nected with the asylum about two years ago, introduces into his report : — 

"When the undersigned entered upon official labours, more than twenty-five 
per cent, of the hundred and twenty patients in the house presented that most 
hopeless state of disease, epilepsy and chronic insanity combined. Fully sixty 
per cent, of the remainder had long since lapsed into the chronic stage of their 
maladies, and, of course, presented a gloomy prospect of any gratifying degree 
of improvement ; while among the comparatively recent, and even the few acute 
cases, a majority seemed unpromising. All had seriously suffered during the 
previous winter, and many, particularly the epileptics, exhibited evidences of 
the evil effects of cold, damp atmosphere upon weak and diseased bodies. This 
exposure and suffering resulted from unavoidable necessity to confine most of 
the patients, during the long and inclement nights of winter, in rooms destitute 
of any artificial warming. But few of such patients — and they are of a class 
who bear the influence of cold with comparative impunity — could, with safety to 
themselves and the house, be allowed stoves or open fires in their lodging rooms. 
And the irregular and often deficient supplv of water for steam and other pur- 
No. LXXIX. — July 1860. 13 



194 Bibliographical Notices. ' [July 

poses, added to the inefficiency of the steam apparatus, broken and deranged 
condition of the steam and water pipes, as well as water tanks, rendered it not 
only impracticable, but utterly impossible to warm the halls or lodging apart- 
ments of the sufferers. 

"For the rigours of the winter of 1858-9, the house was as ill prepared as for 
those of the preceding. The consequences were, much suffering by the patients, 
several deaths, and most of the survivors weakened, and more or less seriously 
worsted, before the close of cold weather. To add, as it were, to existing diffi- 
culties, as the genial warmth of spring came, epidemic dysentery invaded the 
feeble household. Before the close of July, about eighty cases of this disease 
had occurred, and ten of them terminated fatally. Several of the stoutest at- 
tendants, and other helps, suffered also, but were promptly relieved. In conse- 
quence of drought, the cistern water failed about this time — a serious misfortune 
even alone ; now a great and perplexing evil. Early in August, miasmal 
bilious fever, of a violent grade, appeared in the country, and was soon in the 
asylum. Dysentery seemed to run into " the fever," as it has been often observed 
to do in general practice. Here, as in the neighbourhood, the force of this 
" bilious" disturbance being primarily upon, or borne by, the brain and spinal 
cord and mucous coat of the bowels, the fever appeared to be of the apoplectic 
and dysenteric character. And it is a remarkable fact, that scarcely an indi- 
vidual who had convalesced, or who was recovering from a recent attack of 
dysentery, escaped an attack of this fever. And, of course, many of such 
patients soon succumbed to its fatal force." 

Causes of Death. — Epilepsy and paralysis, 9 ; paralysis, 8 ;. apoplexy, 3 ; epi- 
lepsy, 4 ; consumption, 8 ; miasmal fever, 7 ; dysentery, 10 ; maniacal exhaustion, 
2 ; gangrene of legs, 2 ; inflammation of stomach, lumbar abscess, and cancer of 
the uterus, 1 each. 

" Epilepsy, of many years' standing, was complicated with miasmal fever and 
dysentery in 5 of the 17 who died of these acute bilious affections ; as the latter 
in turn seemed in many instances to give fatal force to all of the other causes of 
death above specified. Ulceration of the bowels existed in almost all who died — 
from what cause soever — during the prevalence of the fever and dysentery." 

Of the 337 patients who were in the asylum in the course of the two years, 
50 were epileptics, and 29 congenital idiots. Eight cases enter into both of these 
classes, epilepsy and idiocy being associated in them. 

We notice a little discrepancy in regard to the mortality among the patients. 
While, in one place, as has been quoted above, some special physical disease is 
mentioned as " the cause of death" of every patient, it is stated, in another, that 
one " died by homicide, committed by a stout maniac, in a sudden and violent 
fit of excitement," and " another, a female, committed suicide during the second 
night after admission, by tightly tying a cord around the neck." 

Although Dr. Montgomery finds some cause for discouragement in the new 
field of labour which he has entered, we trust that he will not forget the potency 
of patient and persistent effort. P. E. 



Art. XIX. — A Familiar Forensic View of Man and Law. By Bobert B. 
Warden. Columbus : Follett, Foster & Company, 1860, 8vo. pp. 550. 

This work is a lawyer's view of man and law. It is professedly an attempt to 
shed the light of other sciences on legal learning, and to shed the light of legal 
science on other learning ; or, in other words, to bring jurisprudence into the 
circle of the other sciences. It claims to be merely the introduction to an un- 
published volume which is to treat of polity and jurisprudence chiefly, of the 
development of art and law, of jural forms and other objects of interest, in a 
forensic view of man and law. 

The stand-point of this view is not, however, purely forensic. The author 
avowedly preferring the comprehensive to the narrow, attempts the study of 
anthropology in its scientific and metaphysical, as well as its legal aspects. In 



I860.] Warden, Forensic View of Man and Law. 195 



the initial chapters of his work, he speaks of the first appearance of man in na- 
ture and art, of the brotherhood involved in unity of origin, and of man in his 
legal character and zoological rank. In the second book, which constitutes by 
far the greater part of the volume, the forensic relations of physiology, pathology 
and etiology, are discussed at some length. 

In the ethnological remarks embodied in chapters two, three, and four, Mr. 
Warden is particularly unhappy. He is very positive in his opinions concerning 
the origin aud affiliation of the races of men, notwithstanding that the scientific 
data thus far collected, are far from being sufficient to warrant an authoritative 
conclusion upon these deeply important questions. He is " determined to re- 
spect the account of the appearance of man which Agassiz rejects." He tries 
a lance with Morton, talks confidently of the " arrogance of science," and thinks 
that "life forensic" has enabled him to judge " of the limits in which scientific 
theories deserve acceptance." In matters of science he opposes Blackstone and 
Moehler to Agassiz and all those who have chosen to depart from the received 
construction of Genesis. He thinks that " the narrative in Genesis must be 
regarded as asserting that all mankind are derived from a single pair, and that 
to construe away the meaning of the narrative is wholly to destroy the narra- 
tive in all its parts." He makes issue with Agassiz in relation to the adapted- 
ness of different animals and plants to certain geographical regions, and because 
he cannot discover in what this supposed adaptedness consists, he concludes 
that we are not authorized to say that it exists at all. The thoughtful reader 
will be slow to accept the conclusions arrived at by such reasoning as this. As 
well might we say that light does not exist, because the most eminent physicists 
are not yet agreed whether this imponderable consists of material emanations 
or of ethereal undulations. 

Our author, very justly, we think, finds in the " harmonious relation of the 
human mind and the human body" the proper basis of his forensic view of man. He 
seeks a reliable psychology suited to his purpose among the facts of physiology 
rather than those of the metaphysical philosopher. 

" A physiology, distinctively forensic," he writes, " must embrace some views 
of life, which physiology, as part of medicine, does not include. As obviously, 
the forensic physiology cannot present minutely all that medical accounts and 
theories of life elaborate. 

" How human life is reproduced in individuals, all physiology inquires. What 
regulations should be made with reference to the reproduction of life, forensic 
physiology adds to the questions asked in other physiologies. When life begins, 
all physiology attempts to ascertain. The duty of the government with reference 
to the protection of human life, may be examined with peculiar interest in a fo- 
rensic physiology. How life may be destroyed — how it may be affected bene- 
ficially or otherwise — are questions with which the medical physiology must.be 
especially familiar. They are questions also of great interest in a forensic phy- 
siology. How life may be supplied with liberty of action; what should be the 
limits of its freedom ; how it may pursue its objects ; how its powers may be 
used in legal service, in the national defence ; and otherwise in public duty — 
what may work a forfeiture of life, or of the liberty so dear to it — these ques- 
tions also might, perhaps, be treated as belonging to a distinctively forensic view 
of life." 

Finding in physiology, therefore, the true basis upon which to erect a legal 
philosophy of man, Mr. Warden reproduces from the works of Carpenter, Dra- 
per, Morton, Wilson, Dunglison, and others, many well-known details concerning 
the structure of the eye and its connections, the minute anatomy of the nerves-, 
the nature of nerve-force and mind-force, &c. He presents the reader also with 
a brief summary of what is known concerning perception, the varieties of cere- 
bration, hallucination and illusions, the understanding and the will. In this 
manner he attempts to portray the characters of what he calls an ideal standard 
man and woman. He treats, finally, of life in its beginnings, and in its juvenile, 
adolescent, and senile periods ; of idiocy and the varieties of madness, and of the 
facts of pathology and etiology in their relation to jurisprudence. 

From these remarks it will be seen that the author of the work before us car- 
ries his readers over quite an extensive field. He seldom, however, plunges 



196 



Bibliographical Notices. 



[July 



with them below the surface. His work, though comprehensive, is certainly not 
profound. It is commendable more for the philosophical importance of the 
subject, and the great value of the method of investigation adopted, than for 
the thoroughness with which that investigation has been conducted. It is an 
exceedingly difficult undertaking to keep pace with the rapidly advancing phy- 
siology of the present day ; still more difficult is it for any one to master the 
details of this science so thoroughly as to be able to apply them with success to 
the elucidation of the principles involved in a forensic survey of man. For such 
an application something more than the mere perusal of the standard, physiolo- 
gical text-books of the day is necessary. Years of laborious and patient re- 
search in the laboratory of the physiologist are imperatively required. 

J. A. M. 



Art. XX.— -De V Hematocele Rilro-uUrine et des Epanchements Sanguins Non- 
enkyste's de la Gaviti. P&ritoneale du petit Bassin, considires comme Accidens 
de la Menstruation. Par le Docteur Auguste Yoisin, Ancien Interne des 
Hopitaux de Paris, Laureat de la Faculte de Medecine et de la Societe de 
Chirurgie, Membre de la Societe Anatomique, de la Societe Medicale d'Obser- 
vation, de la Societe de Medecine du Departement de la Seine. Avec une 
planche. Paris : J. B. Bailliere et Fils, 1860. Octavo, pp. 368. 

Retro-uterine Hematocele and Non-encysted Effusions of Blood in the Peri 
toneal Cavity, considered as Accidents of Menstruation. By Dr. Voisin. 
With a lithograph plate. 

Retro-uterine Hematocele is the name given by M. Nelaton to an affection, 
the pathology of which was first precisely pointed out by him about ten years 
ago. The character of the affection is indicated by the name ; it is a bloody 
tumour behind the uterus. 

With the exception of a few very short notices in some of the medical peri- 
odicals, a very imperfect, and indeed quite incorrect, account given by Dr. Gross 
in his System of Surgery, and three cases reported by ourself from the clinical 
lectures of M. Nelaton, we have never seen any reference made to this affection 
by an American writer. British writers, also, have said but very little in regard 
to it ; by far the most complete account of all is given by Dr. West, in his Dis- 
eases of Women (Am. ed., Philadelphia, 1858, p. 333) . 

This affection, so lately recognized, is certainly not a common one ; yet a 
knowledge of its existence and of its nature will show it not to be so very rare 
as might be supposed. We are satisfied ourself that a very considerable pro- 
portion of the reported cases of pelvic abscess so readily healed after opening, 
and of ovarian tumours cured by simple evacuation through the walls of the 
vagina, would be shown, by more careful and enlightened examination, to be 
cases of sanguineous cysts behind the uterus, or retro-uterine hematocele. The 
situation occupied by these sanguineous cysts, and the gravity and peculiar 
character of the diseases with which they may readily be confounded, show the 
importance of recognizing them. 

This treatise of Dr. Voisin is one of those complete and finished monographs, 
in which the French, with their genius for methodical arrangement and careful 
research into minutiae, so highly excel. It contains all that is known in regard 
to retro-uterine hematocele ; its literary history ; its pathology, and the different 
opinions held in regard to it; its causes; its symptoms, its diagnosis, and its 
treatment ; and, moreover, the detailed history of thirty-six cases. Not only 
this, but its author, in addition to being thoroughly acquainted with his subject, 
is evidently highly qualified for the task of deciding between any discordant 
opinions that may have arisen in regard to various points connected with it. 
After carefully studying his treatise, we adopt, without hesitation, the opinions 
he holds with respect to the origin of the blood, and the anatomical seat of the 
tumour — the two most unsettled points in these cases of bloody tumours, en- 
cysted and not encysted, of the pelvis. 



I860.] 



Y oi sin, Retro-uterine Hematocele. 



197 



Retro-uterine hematocele is the result of hemorrhage into the fold of the 
peritoneum, behind the uterus, from the mucous membrane of the Fallopian 
tube, or of the uterus, or of the membrane of the Graafian vesicle. It always 
takes place at the time of the menstrual discharge, the determination of blood 
to the pelvic organs having been abnormally great. Xon-encysted effusions of 
blood proceed from the same parts, the hemorrhage being so violent that the 
patient dies before the blood effused can become surrounded by a limiting mem- 
brane; and also from a ruptured sub-ovarian varix, when the hemorrhage is 
always so rapid that the patient dies (not one has lived more than twelve hours) 
before there is a possibility of any cyst being found. In ten of the cases of 
hematocele that came under his own notice, Dr. Yoisin was able to obtain 
precise information respecting the direct cause of the affection. In all the ten 
the first symptoms coincided with the catamenial period. In seven sexual inter- 
course had taken place while the courses were on, and a commencing pain was 
produced during the venereal act. In the others, one had passed the whole 
night at a ball ; another had scoured a floor ; and another had washed clothes, 
exposed to severe cold. In two cases of non-encysted bloody effusions, in which 
an autopsy was made, the direct cause in one was evidently excess in coitus, and 
the other was caused by a kick. 

As to the seat of the tumour, autopsy has always shown it to be situated in 
the peritoneal cavity; no proof has ever been given of the extra-peritoneal seat 
of retro-uterine hematocele. As regards the opinion, adopted by Dr. Gross, that 
the blood is poured out into the sub-peritoneal cellular substance of the neck of 
the uterus, it is only necessary to state that there is not a trace of cellular 
tissue, on the posterior surface of the uterus, between it and the peritoneum. 

The symptoms of retro-uterine hematocele, at the beginning, are those of 
inflammation of the peritoneum ; severe pain, increased by the least pressure, 
by the slightest motion, having its principal seat in the pelvic cavity, increasing 
at every menstrual period as long as the affection lasts. The pain is sometimes 
accompanied by a very fatiguing sensation of weight about the anus ; then the 
patient or the physician detects the existence of a tumour, dull upon percussion, 
projecting above the pubis, and extending more or less towards the umbilicus. 
By the finger in the vagina, this tumour is felt pushing forwards the neck of the 
uterus against the posterior face of the symphysis pubis, flattening out the 
rectum behind, stretching tightly the wails of the vagina, and advancing for- 
wards to about two inches from the orifice of the vulva. From interference 
with the bladder and the rectum, there is vesical tenesmus, and constipation. 

The general symptoms are those of peritonitis ; nausea, vomiting, chills, 
intense fever, small and rapid pulse, and hippocratic face. To these general 
phenomena must be added a rapid decoloration of the skin, which becomes of a 
dull white colour. 

"When left to itself, a retro-uterine hematocele generally disappears, by the 
absorption of the blood effused, in about four months. In some instances it has 
opened its way into the rectum, and in others — and of this we have witnessed 
an example — it has discharged itself into the vagina. In some few cases the 
encysting membrane has given way, and the tumour has opened into the general 
peritoneal cavity; and again — though this is very rare — the contents have 
become purulent, and demanded instant surgical intervention. 

As to the proper treatment of this affection, we learn from this treatise that 
out of 27 cases treated medically, but 3 died; of 20 cases in which a puncture 
was practised, and the contents of the cyst evacuated, 5 died, and a large pro- 
portion of the others were in great danger with symptoms of putrid infection. 
It is only in those very rare cases where suppuration takes place in the tumour 
that the surgeon should interfere. Dr. West is decidedly too much inclined to 
practise the opening of these sanguineous cysts ; a more extended experience 
will probably lead him to modify his teachings in regard to this. 

TTe stated above that it was likely that a number of cases of retro-uterine 
hematocele were confounded with pelvic abscess, that kind, at least, which is 
situated behind the uterus. In both cases there is a post-uterine tumour, and 
very severe pelvic pains ; in both, also, adhesions are formed between the intes- 
tines and the pelvic organs. But in post-uterine abscess the symptoms are not 



198 



Bibliographical Notices. 



[July 



often so closely connected with menstruation, and do not from the very first 
reach their highest degree of intensity ; the tumour is not formed at the very 
beginning ; the mass, hard at first, becomes afterwards soft and fluctuating, 
while generally it is the contrary in hsematocele. Eetro-uterine abscess is very 
often consecutive to a delivery or an abortion. Another affection also con- 
founded with retro-uterine hsematocele, but the differential diagnosis of which is 
far more easy, is an ovarian cyst occupying the retro-uterine space, and adherent 
to the broad ligaments, the uterus, and the intestines. The tumour here pushes 
the uterus forwards ; it is felt by the touch above the pubis, and is the seat of 
evident fluctuation. But in such cases the patient is generally over forty years 
of age, while in hsematocele she is almost always about thirty; the affection is 
developed without any serious morbid symptom, without any sign of acute peri- 
tonitis, and it tends to daily increase in size, without giving rise to any symptoms 
but those of compression and of interference with the functions of the alimentary 
canal. 

The plate accompanying this work represents the appearances found in the 
pelvis in a case of retro-uterine haematocele, as examined after death ; also three 
figures illustrating a case of cystic tumour of the ovary. 

We most earnestly recommend the careful study of this monograph of Dr. Yoisin 
to all engaged in medical practice, and particularly to those who are interested 
in the subject of abdominal tumours. It has been our object, in what has been 
said on the occasion of his work, rather to draw the attention of the profession 
in this country to the existence of the disease treated of therein, and to the 
importance of recognizing it, than to attempt anything like a critical or analyti- 
cal notice of its contents. W. F. A. 



Art. XXI. — Stricture of the Urethra: its Complications and Effects. A Prac- 
tical Treatise on the Nature and Treatment of those Affections. By Robert 
Wade, F. R. C.S., Senior Surgeon to the Westminster General Dispensary; 
Fellow of the Royal Medical and Chirurgical Society ; and late Lecturer on 
Pathological Anatomy. Fourth edition (with engravings), considerably en- 
larged. London, 1860. 8vo. pp. 354. 

In the preface to this treatise we are warned that it has no pretensions to 
either microscopical or historical distinction, and that the end and aim of the 
author have been to make it thoroughly practical. We are therefore, we sup- 
pose, called upon to excuse the absence of anything approaching to novelty or 
to remarkable interest in this good-sized volume, in the matter of the anatomy, 
physiology, pathology, or hygiene of the urethral canal ; in other words, of 
everything not directly concerned in the treatment of stricture. In what we 
have to say about it, we shall therefore confine ourselves almost entirely to its 
practical teachings, or to the mode of treatment advocated therein. Since the 
author seems to disclaim any intention of affording any new information on other 
points, we scarcely feel at liberty to find fault with him for not having done so, 
though quite disposed to express dissatisfaction at the waste of time we have 
been compelled to submit to in the examination of so many pages devoted to 
the description of the varieties, symptoms, causes, and consequences of urethral 
stricture, without finding anything to repay us for our labour. 

This absence of anything new is, to be sure, scarcely a matter for just disap- 
pointment, when we consider how much has been written on this subject, and 
the number of comprehensive treatises that have recently been published there- 
upon, particularly in England. But, on the other hand, this same consideration 
would lead us to expect some decided superiority in a treatise, of which a fourth 
edition had been demanded. This difficulty, however, we find satisfactorily 
solved by what is said of the second edition of the work in the British and 
Foreign Medico- Chirurgical Review, for April, 1850. Speaking of Mr. Wade, 
the reviewer says : "He has imposed upon the public, and has attempted to 
impose upon us, a book which he calls a second edition, but which is not by 



I860.] 



Wade, Stricture of the Urethra. 



199 



any means truly a second edition. Struck with a difference, although a very 
slight one, in the colour of the paper of the two parts of this book, and a certain 
appearance of age which appertains to the first part, a suspicion flashed across 
our mind, which we have taken the trouble to verify by comparison of the first 
and second editions of this book. A second edition of any work implies that 
the former edition has been sold and disposed of, and that the public requires a 
fresh supply; which is in some sense a guarantee that the book is a good one, or 
at all events a popular one. What will our readers think when we tell them 
that this second edition of Wade on Stricture of the Urethra, is nothing more 
nor less than the old book, with the addition of ninety-eight pages of new print- 
ing, if not altogether of new matter, tacked on to the end of it ? In fact, Mr. 
Wade's old performance, which has never sold, has been taken from the musty 
shelves which bore the precious burden, and, with the embellishment of a new 
title-page, a newly printed preface, and the addition we have before mentioned, 
has been issued to the world in a new binding as a second edition, greatly en- 
larged." After this disclosure, it is easy to understand what was before rather 
incomprehensible, a great demand for Mr. Wade's Treatise ; and knowing now 
the demand to be little, and the supply great, we are in a position to estimate 
the relative value of the production. 

In the portion of the book devoted to the treatment of stricture, as may be 
known from what has already been said of it, we do meet with novelties, or at 
least with peculiarities, calling for remark. As is well known, there are strong 
objections to the employment of caustics in the treatment of stricture. Their 
uncertainty, the swelling of the urethra and consequent retention of urine often 
following their application, and the fact that the tissue destroyed by them is 
replaced by a cicatrix which afterwards produces a new obstacle ; these are 
some of the more important reasons why, at the present day, prudent surgeons 
seldom or never resort to their use. Let any one reflect for a moment at the 
difference in length possessed by the urethral canal, according to the degree of 
turgescence of the penis, or the greater or less degree of force with which the 
surgeon stretches the organ, when holding it for the introduction of his instru- 
ment, and he will see how impossible it is to make a small piece of caustic touch 
exactly a certain part of the canal. Again, if the opening at the stricture be 
very small, the swelling that must follow the action of the caustic may close the 
canal entirely, and retention of urine, with all its suffering and danger, is the 
consequence. These are the immediate difficulties and dangers of cauterization, 
to say nothing of hemorrhage, perineal abscess, false passages, the severe pain 
inflicted upon the patient, and its ultimate results, in respect to which experi- 
ence has decided most unfavourably. 

Mr. Wade, however, in his treatise, tells us that cauterization, in his hands, is 
never attended with these disagreeable consequences. The caustic he uses is 
the caustic potash ; he applies it more freely than others have done, and in 
impassable and highly irritable strictures, and declares that "he can truly say 
that the application of the caustic potash to urethral stricture, in his hands, 
has never been attended with any results which have caused him the slightest 
anxiety." (p. 114.) This is a startling assertion. 

"The marvellous," says an ancient surgical writer, "is the rock whereupon 
the learned and the ignorant make shipwreck ; the former, determined to believe 
nothing blindly, deny all the facts they are unable to understand ; the latter, 
wondering at everything, and unacquainted with the impossible, believe every- 
thing without discernment: led on either side by different prejudices, they fall 
into opposite extremes : a blind credulity embraces the coarsest errors, and an 
exaggerated distrust rejects resolutely many truths that ought at least to cause 
hesitation in minds free from prejudice." 1 To show how Mr. Wade's reported 
cases of success have been judged, we may state that Mr. Syme, at page 53 of 
his own work on stricture, declares that " on the whole it seems more reasonable 
to conclude that in the eases of alleged cure by caustic there was no real stric- 
ture in existence, than to suppose that so improbable, or rather impossible, an 
achievement had been accomplished." This declaration, coming as it does from 

1 Memoires de l'Academie Royale de Chirurgie, tome iii. p. 32. Paris, 17G4. 



200 



Bibliographical Notices. 



[July 



a surgeon, who, though greatly distinguished in his profession, is known to be a 
warm partisan of the treatment of stricture by incision, may be justly received 
with some distrust. Nevertheless, after carefully examining the chapter in Mr. 
Wade's book devoted to cauterization, and the numerous cases appended to it, 
endeavouring at the same time, as far as possible, to be uninfluenced by what we 
have read and ourselves witnessed of the action of caustics in the urethral canal, 
we have arrived at the same conclusion. 

The caustic employed by Mr. Wade, as said before, is the potassa fusa. He 
uses it in old hard strictures, particularly such as are impermeable and of con- 
siderable extent ; in highly irritable and very vascular strictures, which readily 
bleed upon slight pressure by the bougie; and in those strongly predisposed to 
spasm. It is applied by inserting a small piece newly broken, about the size of 
a pin's head to commence with, into a hole made in the point of a soft bougie, 
leaving it fairly exposed, so as to enable it to act upon the stricture. Covering 
it well with lard that there may be no fear of its acting before it reaches the 
stricture, it is introduced into the urethra, pressed gently against the stricture 
for a minute or two, if impermeable, and then withdrawn ; if the stricture be 
permeable, the bougie is passed three or four times over its whole surface. The 
period at which it will be advisable to repeat the application of the potassa fusa 
depends upon its effects and the nature of the cases in which it is used. In many 
old chronic strictures, Mr. Wade states that he has used the potash advantage- 
ously every second or third day ; and in some few instances, under peculiar cir- 
cumstances, even oftener. 

Used in this way we are told that the potassa fusa appears to exert its salutary 
effect by a process of inflammatory softening and dissolution of the thickened 
tissues forming the obstruction. Of this powerful solvent effect, as Mr. Wade 
styles it, of the potassa fusa there can be no doubt ; but when pressed down in 
this way in the urethra, particularly against the anterior extremity of a hard, 
diseased mass, the orifice of which the finest bougie cannot penetrate, what is 
to limit this powerful solvent effect to the strictured canal alone? No wonder 
that perineal abscesses, false passages, and exhausting hemorrhages, from de- 
struction of other parts than those for which it was intended, have again and 
again followed its use. Why they never do in Mr. Wade's hands, why he never 
has had results "that caused him the slightest anxiety," we are at a loss to un- 
derstand, for the only peculiarity in his mode of using it, is the greater quantity 
of caustic employed, and its more frequent and general application. How it is 
that others have not been equally successful with himself in the treatment of 
stricture by caustic, Mr. Wade would explain by saying that to use it success- 
fully often requires a considerable degree of confidence derived from experience, 
and then he asks, " Do we not constantly find in practice that a particular remedy 
proves more successful with one person than with another?" (p. 108.) Now, 
surely great confidence could only lead to greater boldness and freedom in the 
use of the caustic, which cannot explain this limitation of its solvent effect, and 
consequent absence of disastrous results, and we are thrown back upon this 
explanatory question, upon which we leave our readers to make their own com- 
ments. 

The cases contained in the appendix to the chapter upon cauterization are 
forty-eight in number. They were all judged to be either impassable or highly 
irritable, often upon what appears to be very insufficient grounds, and immedi- 
ately thereupon subjected to the potassa fusa. In reading them over one is 
irresistibly reminded of what he has read of the witch-trials of ancient days, 
where one unfortunate wretch after another is recorded as convicta et combusta. 

W. F. A. 



I860.] Smith, Haemorrhoids and Prolapsus of the Kectum. 201 



Art. XXII. — Haemorrhoids and Prolapsus of the Rectum: their Pathology and 
Treatment ; ivith especial reference to the application of Nitric Acid. By 
Henry Smith, F. E. C. S., Surgeon to the Westminster General Dispensary ; 
formerly House-Surgeon to King's College Hospital. Second edition. Lon- 
don, 1860. 12mo. pp. 108. 

If we are to judge from the number of works recently published upon diseases 
of the urethra and of the rectum, these diseases must be at the present time, either 
from choice or from necessity, a principal subject of attention with surgeons. 
In England particularly is this the case, and as a general rule, therefore, a pub- 
lication upon these diseases contains very little that is new, if it possesses even 
any distinguishing peculiarity. 

The main feature in the little work before us is the satisfactory account it 
gives of the treatment of haemorrhoids and of prolapsus recti, by the application 
of nitric acid. Although Mr. Smith, in the preface, declares that he has taken 
the opportunity to consider, at some length, the pathology and general treat- 
ment of the diseases in question ; yet we have found it to contain nothing calling 
for particular remark, on any other point than that of their local treatment by 
the acid just mentioned. On this point the information given is really very valu- 
able, and we could have been in no-ways disappointed in the book had we not 
been led from the statement in the preface to look for something more. There 
is, it is true, a short account given of the pathology and general treatment of 
haemorrhoids and of prolapsus recti, particularly of the former affection ; but 
this account contains nothing but what we find in every work treating of diseases 
of the rectum. This is the more to be regretted, because there is an opportunity 
to say much that is new and important upon hemorrhoidal affections, as well as 
upon all those in which the venous system is concerned. On affections of the 
veins, surgery is further in arrears than on almost any other subject. 

The treatment of internal piles (of external, excision is agreed by all to be the 
best treatment) by the local application of nitric acid, although highly extolled 
by recent writers on surgery in England, has not been favourably spoken of in 
this country, at least so far as we have been able to know. Druitt,' who may 
be regarded as a reliable exponent of the most judicious surgical practice in 
England, says that "it is the most safe, speedy, and effective means" of affording 
relief in cases of internal piles; that "it is difficult to exaggerate the benefits 
of this plan of treatment." In this country Dr. Gross writes that he "has occa- 
sionally made use of nitric acid for destroying internal piles ; but with results 
not sufficiently gratifying to induce him to recommend its adoption as a means 
of radical cure, being satisfied that, while it is more difficult of application and 
productive of more pain and inflammation than the ligature, it is much less cer- 
tain in its effects and more liable to be followed by relapse." 

When, in a matter of experience, such a difference of opinion exists in regard 
to the effect of a certain remedial agent, it is probably owing to some difference 
in the method of applying the agent, or to some difference in the nature of the 
cases. How Dr. Gross has thus unsatisfactorily attempted to apply the nitric 
acid, or in what cases, he does not state ; but it may be, since its effects are so 
highly praised by others, that it was not applied properly, nor in suitable cases. 
As Mr. Smith is a prudent and conscientious surgeon, in whose statements per- 
fect reliance may be placed, we shall, therefore, take the pains to describe bis 
mode of using the caustic, and to distinguish the particular cases in which he 
found it beneficial. Upon these points, moreover, he is very clear and definite. 

The local use of nitric acid, according to Mr. Smith, is eminently suited to 
cases where the haemorrhoidal tumours are small or moderate in size, and where 
they are evidently composed of morbid texture, in which the small arteries rather 
than the veins are interested. About these particular kind of cases, he adds, 
there is no doubt in the mind of any surgeon who has seen the nitric acid applied 

1 System of Modern Surgery, Amer. edit., from the 8th English. Phila., 1860. 



202 



Bibliographical Notices. 



[July 



in a proper manner. Again, in cases where there is not so much any decided 
hemorrhoidal tumour, but where there is a generally congested and relaxed 
condition of the mucous membrane of the rectum, attended with bleeding to a 
greater or less extent, the nitric acid acts very beneficially. To apply this 
agent to those cases where the tumours are large and indurated, and have a 
deep blue colour, would be, he declares, perfectly useless, and only bring discredit 
upon the nitric acid as a means of cure in other kinds of hemorrhoidal disease. 
For cases such as these last mentioned, he states that the ligature is necessary ; 
as also in those instances where, though of a bright-red colour, the dependent 
portions have become very much thickened and indurated ; and in those where 
a considerable amount of prolapsus attends upon the original affection, and an 
alarming amount of hemorrhage proceeds from one distinct tumour. 

In applying the acid, the bowels having been well evacuated some hours pre- 
viously, the haemorrhoidal disease is brought into view by making the patient sit 
over hot water for a few minutes, or by means of an enema of water thrown into 
the rectum, the surgeon then lightly touches the diseased surface, previously 
wiped with lint, with the extremity of a small, flat piece of wood dipped into nitric 
acid, the strongest and purest that can be obtained. The part touched, and the 
neighbouring mucous membrane, are then well smeared with oil, and the whole 
of the exposed part is returned within the anal orifice. When it is difficult to 
expose the parts, a silvered glass speculum may be used. The pain following 
this operation is very slight, there is merely a slight smarting or warmth, which 
goes off very speedily; it is not necessary to confine the patient to bed after- 
wards ; and in no instance has anything like a dangerous result ever been wit- 
nessed. After the operation by the ligature, a patient should be confined to his 
bed for several days ; the process of applying the ligature is attended sometimes 
with considerable pain ; and life has been destroyed by tetanus, by pyaemia, and 
by low inflammation of an erysipelatous character spreading along the intestinal 
canal. 

With the evidence now afforded us, we think it may safely be concluded that 
in certain forms of hemorrhoidal disease, which forms are definitely marked and 
easily recognized, the application of nitric acid is superior in safety, in comfort, 
and in rapidity of cure, to the operation by the ligature. 

In prolapsus of the rectum, in those cases where the prolapsus is of large size 
and of very long standing, where the mucous membrane has become very much 
thickened and changed in its structure and appearance, the acid, according to 
Mr. Smith, will do little or no good. In those cases, however, of simple pro- 
lapsus, where there are one or more large folds of mucous membrane continually 
down, and where the tissue is extremely vascular, presenting the appearance of 
smooth velvet, or is perhaps superficially ulcerated and readily bleeds, the strong 
nitric acid, he declares, will act like a charm. 

A large number of interesting cases, both of haemorrhoids and of prolapsus, 
are detailed by Mr. Smith, for the purpose of illustrating his statements in regard 
to the operation, both of the nitric acid and of the ligature, in these troublesome 
affections. 

This little publication, therefore, must be considered as one of very consider- 
able value, and as well worthy of the attention of surgeons. W. F. A. 



Art. XXIII. — Exposition of a Method of Preserving Vaccine Lymph, fluid 
and active; with Hints for the more Efficient Performance of Public Vacci- 
nation. By William Husband, M. D., Fellow of the Royal College of Sur- 
geons of Edinburgh, and one of the Medical Officers of the Koyal Public 
Dispensary and Vaccine Institution, Edinburgh. 12mo. pp. 46 : London, 1860. 

While the physicians of the United States employ invariably the dry vaccine 
crust for the purpose of vaccination, those of Great Britain, and we believe of 
Europe generally, prefer the fluid lymph taken from the vaccine vesicle about 



I860.] Husband, Method of Preserving Vaccine Lymph. 203 



the commencement or termination of the seventh day — previously to the forma- 
tion of the areola. That the dry crust, when reduced to the consistency of 
cream by the addition of pure water, and inserted into the arm, will produce a 
genuine vaccine infection, affording as effectual a security against the subsequent 
occurrence of smallpox as when vaccination is performed with the recent 
lymph has been established by so large a body of facts collected by different 
observers, and in different localities, as to place it beyond all reasonable doubt. 

There are two important reasons for preferring the dry vaccine crust over the 
fluid lymph for infection, admitting that the two are equally efficacious. The 
one is that we thereby avoid the necessity of interfering with the vesicle formed 
upon the arm in order to obtain our supply of lymph, and the danger thence 
incurred of rendering the vaccination less complete and effective. The second 
reason is that, in the dry crust the vaccine virus can be preserved in a state of 
activity for future use with much greater ease and certainty than in the form of 
lymph ; all that is requisite for the preservation of the vaccine crust being to 
defend it carefully from the influence of the atmosphere and from damp, which 
can always be effected with the greatest ease. 

Ever since the introduction of vaccination, nearly sixty-four years ago, one 
of the leading obstacles in the way of its successful performance and general 
diffusion, has been the difficulty of keeping vaccine lymph fresh and active for 
any length of time. 

Dr. Husband believes, and not without sufficient reason, that the large annual 
mortality from smallpox in Great Britain results in a great measure, perhaps 
mainly, from the continually existing scarcity of lymph, and the ever recurring 
delay in procuring it when it is wanted. 

A remedy for the scarcity of pure and efficient vaccine virus everywhere 
complained of is much to be desired on sanitary grounds. Could physicians 
be kept provided at all times, and in all places, with the means for prompt 
vaccination, it is believed that the protection afforded by the vaccine infection 
would be more generally extended than it now is, and, in consequence, the ravages 
of smallpox would be effectually checked, and a material saving of human life 
effected. 

We are convinced that, with a very little care, and a few simple precautions, 
which can be readily practised, the dry crust will furnish the practitioner a con- 
stant and reliable supply of pure and active vaccine matter, available at all 
times for immediate use. The crust we know from experience maybe preserved 
for a long time, without its undergoing any change capable of impairing its effi- 
ciency, as a means of communicating a full and genuine vaccine infection. All 
that is necessary is to select crusts that are perfect in themselves, and that have 
not been prematurely detached from the arm, and to keep them scrupulously 
dry and secured from the action of the atmosphere. We have never, however, 
succeeded in preserving in the crust the vaccine virus active for so long a period 
as Dr. Husband assures us he has by inclosing pure lymph taken from a vaccine 
vesicle in hermetically sealed glass tubes. This gentleman states that he has 
vaccinated successfully with lymph that had been kept in this way for from one 
to seven years. As the result of a very large experience he has found that, after 
a lapse of from two to two and a half years, lymph preserved according to his 
method may with great certainty be depended upon ; and that too after it has 
been exposed, during several hours daily, to a temperature of between 80° and 
90° of Fahrenheit. 

The plan of preserving vaccine lymph in glass tubes hermetically closed i£ 
by no means a new one. It has been for a very long period pursued by the 
French. From, however, some defect in the tubes themselves, or in the manner 
of charging and sealing them, it has been found that, in a very large number of 
instances, the active properties of the lymph attempted to be preserved in the 
French tubes is entirely destroyed. 

The tubes made use of by Dr. Husband are simple straight cylinders open at 
both ends, having a tenuity that will enable them to be sealed instantaneously 
at the flame of a candle, with a cavity of sufficient size to contain enough lymph 
for one vaccination, and of such a length as to admit of both ends being 
hermetically sealed without subjecting the lymph contained in them to the heat 



204 



Bibliographical Notices. 



[July 



of the' flame. The tubes, besides these conditions, upon which their value as a 
means for preserving vaccine lymph for future everyday use essentially depends, 
must possess sufficient strength not to break easily in the mere handling. 

The average dimensions of the tubes employed by Dr. Husband are as follows : 
Length 2f to 3 inches ; diameter l-28th of an inch; thickness of wall l-200th of 
an inch. Dr. H. does not insist upon an absolute and rigid conformity "to this 
standard, but at the same time, the tubes, he remarks, must vary from it only 
within certain limits, or they become unfit for their purpose. 

In charging these tubes, the vesicles being punctured with a lancet, the end 
of one of the tubes, held in a position more or less inclined to the horizontal, is 
applied to the exuding lymph which immediately enters the tube by the force 
of capillary attraction. As much is to be allowed to enter as will occupy about 
i to £ the length of the tube, according as its cavity is greater or less. The 
lymph within the tube is then to be made to gravitate towards its middle, by 
holding the tube vertically, and if necessary, giving it a few slight shocks, by 
striking the wrist on the opposite arm or the table. In no case should a tube 
be laid down until the lymph is thus made to assume a position in the middle 
of the tube, as the fluid concretes quickly about the orifice, and cannot after- 
wards be easily detached. But if it be made at once to pass from the orifice, 
the tube may be laid down, and half a dozen or more charged with lymph before 
sealing them. The latter process should never, however, be delayed too long, 
over five minutes, perhaps ; as the lymph within the tube is apt, from evapora- 
tion, to become adherent, especially if more than ordinarily viscid, or if the 
calibre of the tube is unusually small, and it cannot afterwards be blown out 
when wanted for use. 

If, in charging the tube the lymph do not exude freely from the arm, the tube 
may require to be drawn several times more or less obliquely across the surface 
of the vesicle or cluster of vesicles, until a sufficient charge has entered. 
Generally, however, if the exudation be copious, and a drop of some size has 
formed, the orifice of the tube need not, indeed ought not to touch the surface, 
but should be merely dipped into the clear fluid. 

In sealing the tube the end at which the lymph entered is to be applied to the 
surface of the flame of a candle. It melts over, and is sealed immediately. The 
other end is to be treated in the same way — it being first, however, plunged 
suddenly — say half an inch — into the flame, and as quickly withdrawn, until it 
touches only the surface of the flame. By simply applying the end of the tube 
to the flame without first plunging it in, there is a danger that, while the glass is 
still soft, the heated air within the tube, by expanding, will form a minute bulb, 
which, from its tenuity, either gives way on the instant, or, what is worse, remains 
entire for a time, only to break afterwards by the slightest touch. This precau- 
tion of plunging the tube into the flame before sealing it is useful, also, in ex- 
pelling a portion of the air, and so leaving less of it to be sealed up along with 
the fluid lymph. 

In order to remove the lymph from a tube for the purpose of vaccination, the 
sealed ends are broken off, and the fluid contents blown out gently on the point 
of a lancet or vaccinator. The activity of vaccine lymph preserved in the 
manner above described, as indicated by the probability of producing with it 
perfectly normal vesicles, we are assured, "is not affected by the length of time 
it has been kept, at least within the ample limit of two years and a half. There 
does not," Dr. H. asserts, " appear to be any tendency at all to deterioration. 
The failures evidently do not increase in number as the lymph increases in age." 

To remove as far as possible all chance of failure with the matter preserved 
in the tubes of Dr. H. it is recommended that vaccination be performed in the 
same subject with the matter of two tubes, taken from different infants. In this 
manner two successive vaccinations with different portions of virus are brought 
to coincide, as it were, and in this manner, provided there is no other cause of 
failure than such as are confined to the lymph itself, we actually square our 
chance of success. 

"I do not mean to say," remarks Dr. H., "that onoe sealed up the lymph 
undergoes no change. I know not what changes may take place in it, but I do 
assert, after a very ample experience of the working of the method for twelve 



I860.] 



Ntjneley, Organs of Vision. 



205 



years, that the properties of the lymph remain entirely unaltered in so far as 
they can be judged of by the effects produced when we vaccinate with, it. I 
never saw any consequences follow from the use of old lymph, which I have not 
equally seen follow from vaccination with fresh matter. However long it is 
kept, it produces the genuine vaccinia, and nothing else. The only fear that 
any one need entertain in vaccinating with it is, that it may fail, but if it have 
been active at the time it was sealed up, and contain no admixture of pus or 
blood, I believe that he maybe almost as confident of success as if he vaccinated 
from arm to arm. Possibly, though I speak here with hesitation, the more 
recent lymph is more likely to produce large confluent clusters, with active 
inflammation round them, while the older — that which is years old — is more apt 
to yield clusters of two or three discrete vesicles, or even a single vesicle, instead 
of a cluster. But the production of even one vesicle is of course decisive of 
the lymph having retained its virtue. It may have undergone a diminution of 
activity, or what is just as probable, it may have been deficient in energy from 
the first. But one thing is certain, that a single vesicle, small, retarded perhaps, 
and which an unpractised eye might suppose had not vigour enough to struggle 
onwards to maturity, is nevertheless as perfectly normal a specimen of the dis- 
ease, as two large clusters would have been. And for the proof of this — take 
of the contents of that imperfect looking vesicle, and vaccinate with them, and 
you will reproduce vaccinia in its utmost apparent vigour. Such is the evidence 
upon which I rest the conclusion that vaccine lymph, the vehicle of the greatest 
gift which, through the instrumentality of medicine, divine Providence has 
bestowed upon mankind, instead of being as perishable as it is precious, is, on 
the contrary, under certain easily attained conditions, highly indestructible." 

We believe that tubes similar to those described by Dr. Husband for the pre- 
servation of fluid vaccine lymph would be well adapted to preserve unchanged 
the dry crust. They can be readily procured, and are well deserving of a tri#l. 

D. F. C. 



Art. XXIY. — On the Organs of Vision, their Anatomy and Physiology. By 
Thomas Nuneley, F. R. C. S. E., Lecturer on Surgery in the Leeds School of 
Medicine, Senior Surgeon to the Leeds General Eye and Ear Infirmary, etc. 
etc. London : John Churchill, 1858. 8vo. pp. 373. 

This monograph is valuable rather as collecting in a single volume a very 
considerable mass of matter before scattered in many places, than as presenting 
for consideration much that is new; but its author is evidently an investigator, 
not content to copy other men's observations without verifying them for himself, 
and such a man can by no means, in these days of transition, go carefully over 
the minute structure of an organ without doing good service, either by confirm- 
ing truths as yet in doubt, by overturning old errors, or perhaps here and there 
bringing forward new facts. 

The book is divided into seven chapters. Of these, three (chapters IT., W., 
and VI.) are strictly anatomical ; Chapter IV. treating of the anatomy of the 
human eye, Chapter V. of the eyes of animals, and Chapter VI. of the eyes of 
fossil animals. The remaining chapters are devoted to the consideration of the " 
senses generally, the feelings and ideas derived from the sense of vision, the laws 
of light as applied to vision, and the physiology of sight. These chapters are 
creditably written, but their style is somewhat prolix, and there is a great deal 
of redundant matter which might have been omitted in a scientific treatise (e. g. 
two poetical quotations from Milton, occupying two pages and a quarter, &c). 
The anatomical chapters are less liable to this objection, and derive additional 
value from the fact that "nothing, so far as he recollects, has been described 
that he has not dissected," a remark which applies in this case to the micro- 
scopical as well as to the coarser anatomy of the organ. Of these chapters, that 
"On the Structure of the Human Eye and its Appendages" (Chapter IV.) is 
elaborately worked up, occupying 172 pages. Personal study, an anxious desire 



206 



Bibliographical Notices. 



[July 



to be exact, and the evidences of considerable anatomical ability, are recognizable 
on every page. At the same time we must confess to considerable disappoint- 
ment at finding two important subjects completely ignored. The first of these 
subjects is the history of the development of the eye and of its component parts, 
a subject which has received considerable attention upon the continent, and 
which is of the greatest moment in determining the homologies and significance 
of certain peculiar and characteristic parts of the organ. From these investi- 
gations the most curious developments have resulted. Thus, the crystalline 
lens, for example, is shown by embryology to be homologous with the epidermis, 
in fact to arise out of the epidermis, the lens fibres being transformed epidermic 
cells. In the development of the eyes the embryonic skin, at the two points 
corresponding to the seats of these organs, projects into the interior in a sac- 
like fold, filled with epidermal cells, very much as occurs in the development of 
the sebaceous glands and the hairs. These cells, by their transformation, pro- 
duce the lens. At first the lens retains its connection with the exterior, but 
this connection (the neck of the sac-like fold) dwindles first into a mere mem- 
brane (the membrana capsulo-pupillaris), then this atrophies, and finally no re- 
cognizable trace of the origin of the lens remains. We owe our knowledge of 
these interesting changes, above all, to 0. Yogt, a brief account of whose results 
will be found in the second lecture of Yirchow's Cellular Pathology. Such 
histories as the above are not mere idle philosophical curiosities, nor are they of 
value only in determining the classification of a tissue with this or that group ; 
they are essential to the right comprehension of the pathological processes of 
the part, and assume from this stand-point, if from no other, a value which it is 
imperative to recognize. 

We much regret, therefore, that the embryology of the eye has been ignored 
in this treatise ; and still more do we regret that the author's plan has not em- 
braced at least brief allusions to the 'pathological anatomy, and especially to 
the pathological histology, of the organ. These subjects are of acknowledged 
importance, and accurate information with regard to them is more difficult of 
access, especially to the student, than is the case with any subject treated of in 
the work. Scattered in foreign and English journals, rich materials have been 
accumulating for the last ten years on these subjects, which it would have been 
in the highest degree useful to render accessible. 

The only reference to the pathological changes of the eye, that we have noticed 
in the volume before us, is at page 254, and the account there given of "the 
opaque cataractous lens," though correct as far as it goes, only describes one 
variety of cataract, a statement which will be appreciated by all who remember 
the excellent article on atrophy of the lens in Carl Wedl's Rudiments. The 
passage to which I refer describes the lens fibres as appearing " as though 
broken up ; they are irregular in outline, the serrations are much less distinct 
and uniform, the fibres are no longer clear and homogeneous, but are granular, 
and separated more or less from each other ; the individual fibres are swelled 
and bulging in some parts, disconnected and broken in others, just as those of 
the healthy lens are after having been subjected to boiling water or coagulating 
reagents. These changes appear to be greater towards the circumference than 
near the centre of the lens." 

This description is illustrated by a drawing, Plate YI. Fig. 11 (incorrectly 
printed in the work as Fig. 14). 

At the same time, however, that we regret the omission of these two important 
subjects, we cannot withhold our meed of praise for the work so far as it goes, 
and we cordially recommend it as a safe and pleasant guide to the student and 
young practitioner. J. J. W. 



Art. XX Y. — TJie Pathology and Treatment of Venereal Diseases, comprising 
the most recent Doctrines on the subject. By John Harbison, F. R. C. S. 
London : 1860. Octavo, pp. 176. 

This volume contains, in a small compass, a very correct account of the pa- 
thology and treatment of venereal diseases. It is well arranged, and clearly 



I860.] Riyaz, Thermal Mineral Springs of Island of Ischia. 



207 



and succinctly written. It is just such a treatise upon the disease as was 
wanted. Eicord's Hunter and Acton are too unwieldy, they contain too much 
for the majority of medical practitioners, and all other special works are too 
imperfect or faulty. As to the accounts given of venereal affections in our sys- 
tems of surgery, or complete treatises, they are remarkably full of errors. 

On two points alone can the doctrines contained in this book be said to differ 
from those approved by the highest authorities on venereal diseases ; and these 
are in respect to the possibility of preventing the infection of the whole system 
by destruction of the chancre, before it has existed a certain time, and in respect 
to chancre, always arising from chancre. Mr. Harrison says, it has been found 
by experience,- that in the case of true syphilitic chancre, cauterization cannot 
be depended upon for the purpose of destroying the syphilitic virus before it 
can be absorbed into the system, and thereby preventing constitutional infection. 
Men of vast experience, who cauterize properly, are positive as to the fact, an 
infinitely more agreeable one to believe, of constitutional infection never taking 
place in those cases where a chancre is properly destroyed within a certain time 
after exposure to contagion. 

In regard to the origin of chancre, Mr. Harrison says : — 

" The question has been frequently agitated, whether the poison of syphilis can 
be generated anew at any time under favouring conditions ? In reference to this, 
I would observe that, from cases which have come under my observation, I am 
convinced that there is always danger of contracting sores, — simple chancres 
at least — incurred by those who indulge in promiscuous sexual intercourse, and 
that even under circumstances when it might be supposed almost impossible 
that any disease could exist. The conditions which tend to favour the genera- 
tion of the poison, I cannot but think, consist mainly in the admixture of the 
secretions of the male and female, altered partly by the irritated condition of 
the organs whence they are derived, and partly by decomposition." (p. 55.) 

The best authorities in the matter are very decidedly against this opinion. 
Opinions differ here, however, just as they do upon the subject of the sponta- 
neous generation of animals and vegetables. From the time of Aristotle and 
perhaps long before him, down to the present moment when the French Academy 
of Sciences is engaged in debating this vexed question, the truth of the maxim 
generatio unius est corruptio alterius, has been a grand subject of dispute. For 
our part we do not believe that the generation of a chancre comes from corrup- 
tion, any more than the generation of an animal ; we hold that every chancre 
comes from a chancre, as well as that every living thing comes from a pre- 
ceding living thing. 

A peculiarity in the spelling of rupia has been adopted by Mr. Harrison ; it 
is always written by him rhupia. The spelling rupia has been sanctioned by 
custom just as much as that of rose, which also, if orthography must always 
be determined by the derivation, should be spelled rhose. This trifle is the only 
thing at all exceptionable which we have discovered in the whole book, after a 
most attentive perusal, so far as respects the manner in which it is written. 

W. F. A. 



Art. XXVI. — Description des Eaux Miniro Tliermales et des Etuves de Vile 
d' Ischia, etc. Par J. E. Chev alley de Rivaz, Docteur en Medecine des 
Facultes de Paris et de Naples, etc. etc. etc. Sixieme edition, Kevue, Cor- 
rigee et Augmentee, 8vo. pp. 214, Naples, 1859. 

Description of the Thermal Mineral Springs and Natural Vapour Baths of the 
Island of Ischia, etc. etc. etc. By J. E. Chevalley de Eivaz, M. D., of Paris 
and Naples. Sixth edition, revised and enlarged. 

There is, perhaps, no place so rich in thermal and mineral springs as the 
island of Ischia, the Pythecusa of the Greeks. Entirely of volcanic origin, the 
subterranean fires to which it owed its birth being still unextinguished, though 
of diminished extent and fierceness, it is not at all surprising that the water of 



208 



Bibliographical Notices. 



[July 



its springs should in so many localities be of an elevated temperature, and im- 
pregnated, to a greater or less extent, with mineral substances ; and that even 
numerous jets of steam should be found issuing from crevices in the soil, which, 
by the most simple appliances, are capable of being formed into the most effi- 
cient vapour baths. 

The curative virtues that have been for ages ascribed to the mineral waters 
and baths of Ischia, together with the balmy and salubrious atmosphere of the 
island ; the beauty of its scenery, as well as the charming prospects which there 
greet the eye in every direction, have always rendered it a favourite resort, not 
only of the valetudinarian, but of those also who desire merely a temporary 
place for relaxation from the cares, vexations, and anxieties of a life devoted to 
business, or from the wearing toil of protracted mental or professional pursuits, 
of all, in short, who desire to recruit their energies, whether of mind or body, in 
a healthful climate, and amid natural objects adapted to afford pleasure to the 
senses while they soothe and invigorate the entire organism. 

Although it may appear at first sight that the island of Ischia is too far off to 
afford a convenient and desirable sanitary retreat for the sick, the overwrought 
minds and bodies of the people of these United States, yet when we consider how 
much nearer even more remote portions of . the earth have been brought to us 
through the aid of steam, it is not impossible that the mineral springs and baths 
of Ischia may even become favourite fonts of rejuvenescence with the rich and 
fashionable of our land. 

In the work before us we are presented with a most interesting notice of the 
island, comprising a concise account of its topography, productions, history, 
and present condition, in respect to population and resources ; a more elaborate 
examination into the physical, chemical, and medicinal properties of its princi- 
pal mineral springs ; their mode of administration as remedial agents ; with an 
exposition of the character of its different natural vapour baths, and their thera- 
peutical application ; and the general rules to be observed by patients during 
the use of the waters, internally or externally, and during their subjection to the 
action of the hot vapours in the form of general or partial baths. 

The hot vapour which issues at different localities in the island of Ischia, 
appears to be nothing more nor less than water converted into steam by subter- 
ranean heat. It contains, at the present day, neither any gas nor mineral sub- 
stance, whatever may have been the case formerly. In respect to the vapour 
which forms the bath of St. Lorenzo, Dr. Breislack supposes that, at one time, 
it was imbued with sulphuretted hydrogen, from the circumstance that in the 
immediate vicinity of this bath there exists a deposit of sulphur. 

The following account of the baths of Castigliona will convey to our readers 
a very good idea of the manner in which the natural steam constantly generated 
by volcanic fires is adapted for use as a vapour bath : — 

" The baths of Castigliona are situated in the midst of Casamicciola, upon an 
eminence composed of an irregular mass of blocks of lava, and projecting in a 
direction towards the sea. At the base of this eminence is the source of the 
thermal spring of the same name with the baths. The latter consist of two 
small buildings, called the lower and the upper baths. In the middle of the first 
is a pit, into which the patient enters, of about six feet in depth, and of less 
dimensions in length and breadth. At the bottom of this pit are the openings 
from which escapes the vapour, of the temperature of 50° + centigrade ther- 
mometer ; the temperature of the external air being about 26°.25 + 0. In the 
vicinity of this pit are other jets of hot vapour, having a temperature of 48°.75+0. 
These are conducted through tubes of burnt- clay, in order that the vapour may 
be resorted to in cases where it is desired that its application should be restricted 
to only certain portions of the body. 

" The upper bath consists of a chamber cut out of the lava, of about 11 feet 
in height by 7 in breadth and 10 in length. It has no other opening than the 
low door of entrance. It is lit by a small dome of glass in the roof. A circular 
bench is placed over a pavement of glazed tiles, around which issue a number of 
jets of hot steam. When closed, the temperature of the chamber is sufficient to 
raise the centigrade thermometer to 44° + 0. Two apartments, kept always in 



I860.] 



Kacle, On Alcoholism. 



209 



excellent condition, are attached to this upper bath as places of repose for the 
bathers. 

" There is no difference between the vapour received into the two baths be- 
sides what results from the amount of water they contain and the degree of heat 
they present. No gas of any kind is disengaged from the vapour— the walls 
continually exposed to its action present no trace of decomposition or of saline 
deposit. The water obtained from it by condensation in a suitable apparatus 
has no other properties than what are possessed by the purest distilled water. 
We are, consequently, to consider as a mere illusion the discovery which a dis- 
tinguished author supposes he had made of a certain principle contained in the 
vapour, which is not otherwheres found in a state of volatilization. We can 
readily suppose, however, that formerly the vapour may have contained certain 
substances of which they, at present, exhibit no trace, the sources from which 
they were derived having become in the course of time exhausted." 

It must be evident that as these vapour baths are simply baths of water va- 
porized by heat, all the effects they are adapted to produce upon the patients 
who make use of them are a softening and relaxation of the skin, an increase in 
the cutaneous transpiration, and of the activity of the capillaries of the surface 
generally. 

Dr. Chevalley de Eivaz enumerates, among the affections in which they have 
been found beneficial, gout and rheumatism, white swellings and scrofulous 
tumours, chronic inflammations of the mucous membranes, contractions of the 
tendons, incomplete ankylosis, different forms of non-febrile dropsy, dysmenor- 
rhcea, various chronic eruptions of the skin, etc. etc. etc. D. F. C. 



Akt. XXYII.— De V Alcoolisme. These presentee cm concours pour Vagrega- 
tion [section de Medecine et de Midecine Legale) et soutenue a la Faculty de 
Medecine de Paris. Par V. A. Ragle, M 6 deem cles Hopitaux, etc. Paris : 
J. B. Bailliere et Fils, 1860. pp. 122. 

On Alcoholism. 

We do not know who invented the term "alcoholism," but it is certainly a 
very excellent one. Based upon etiology, it includes all the evil results of the 
abuse of alcoholic liquors, from mere temporary excitement to hopeless fatuity, 
serving as a sort of family name for the widely diversified phenomena embraced 
between these extremes. 

This subject presents itself in various aspects, in all of which it is highly 
important. To the physiologist and medical observer the effects of alcohol 
upon the individual are of interest, as well as the medico-legal questions which 
arise out of them. Some of the most difficult problems in social science, in 
regard to morals as well as hygiene, come up for solution, if they can be solved 
at all, in connection with these matters. M. Racle's essay is mainly devoted to 
the physiological and medical side of the subject, although he has not allowed 
its other bearings to pass unnoticed. 

Probably the worst types of alcoholism are to be found in Great Britain. 
Drunkenness prevails in Russia also to a frightful extent, as well as among the 
Germanic nations; and in our own country, although it occurs, if we may be 
allowed the expression, sporadically, it yet exerts a most disastrous influence 
upon the well-being of society. In France, whether by reason of the kinds of 
liquor in use, or because the Norman race are peculiarly insusceptible to the 
allurements of intoxication, offensive evidence of the abuse of alcohol would 
seem to be less common than in any other civilized country. Hence a French 
view of the subject of alcoholism is necessarily somewhat interesting. 

M. Racle gives a very good description of the chemical characters of alcohol, 
of the various forms in which it is taken, and of its physiological effects. He 
quotes very freely from the writings of others, but always with due acknowledg- 
ment. Under the head of pathological effects of alcohol, he treats first of the 
No. LXXIX.— July 1860. 14 



210 



Bibliographical Notices. 



[July 



general effects — drunkenness, sudden death, the condition induced by the habit 
of drinking, acute and chronic alcoholism ; secondly, of the organic affections 
thus brought on ; and thirdly, of the influence of alcoholism upon the duration 
of life, upon posterity, and in reference to the degeneration of the human species. 

In connection with delirium tremens, which to the physician is the most im- 
portant of the abnormal conditions brought on by alcohol, on account of its 
frequency and gravity, and of the judgment necessary in its treatment, two 
questions have been mainly agitated of late ; viz., whether the disorder is due to 
a cumulative poisonous effect, or to the sudden abstraction of an accustomed 
stimulus, and what is the line of treatment proper to be pursued. Unfortunately 
M. Eacle passes both these questions over almost entirely, so that we are left in 
the dark as to the opinions of the profession in France in regard to them. ' 

The remaining portions of this essay are extremely concise ; they are devoted 
to different medico-legal and hygienic matters. M. Racle speaks of temperance 
societies as having been found very useful in America, " where they have multi- 
plied since 1813." Without any desire to undervalue these institutions, we must 
remark that their importance was at one time much overrated. Where a mutual 
supervision is exercised by the members, such compacts may be of advantage ; 
but the mere signing of a pledge, in a moment of enthusiasm, has in numberless 
instances proved utterly nugatory against a temptation so besetting as that of 
intoxicating liquors. A tacit but practical acknowledgment of this fact is to 
be found in the circumstance that the opponents of intemperance have almost 
entirely abandoned this method of insuring reform. 

Although this essay of M. Racle's can hardly lay claim to the title of an 
exposition of the subject of alcoholism, it presents a very excellent r6sum6 of 
it, and will at any rate be suggestive to those who may desire to investigate the 
matter more deeply. J. H. P. 



Art. XXYIII. — A Treatise on Medical Electricity, Tlieoretical and Practical, 
and its Use in the Treatment of Paralysis, Neuralgia, and other Diseases, 
By J. Althaus, M. D. Philadelphia : Lindsay & Blakiston, 1860. pp. 354. 

Although a very large majority of those who are engaged in medical or surgi- 
cal practice have, in the course either of their preliminary or of their professional 
education, acquired some general ideas as to the phenomena of electricity, yet 
their knowledge of its laws is, for the most part, much too superficial to enable 
them to employ it therapeutically. The object of the volume before us is, as its 
title indicates, to assist the profession at large in making use of this most pow- 
erful agent in the treatment of disease; and its author may congratulate himself 
upon having materially contributed to the advancement of medical science. 

Dr. Althaus has arranged his subject under five heads, in as many chapters. 
He first describes the different forms of electricity — static or frictional, dynamic, 
including galvanism and electro-magnetism, and animal ; next, its physiological 
effects upon the living organism and its component parts ; in his third chapter 
he discusses the apparatus for its medical application ; fourthly, he treats of its 
use in diagnosis ; and lastly, of its therapeutical employment. Atmospheric 
electricity and lightning form the subject-matter of a brief appendix. 

Under the head of electro-physiology, Dr. A. has given a very interesting 
resume of the results arrived at by Weber, Matteucci, Schb'nbein, Du Bois Rey- 
mond, Nobili, and others. The most interesting portion of this chapter, and the 
most important, is that relating to the electrization of the nervous and muscular 
systems. Dynamic electricity is the form employed in these researches, as well 
as for remedial purposes, on account of the convenience of generating, regulating, 
and localizing it. 

Daniell's battery, consisting of zinc plunged in salt or acidulated water, and 
copper in a solution of sulphate of copper, is the one preferred by Dr. Althaus 
for medical use. It would require a greater space than we have here at com- 
mand to pass in review the various forms of apparatus invented by Oruikshank, 



I860.] 



Althaus, Medical Electricity. 



211 



Middeldorpff, Ellis, Breton, and others, for galvanization, or the application of 
the continuous current of galvanic electricity; or those of Clarke, Duchenne, 
and others, for Faradization, or the employment of localized induction currents. 
Among the former, Pulvermacher's chain has obtained much favour in this 
country; among the latter, we believe that the magneto-electric apparatus of 
Davis is most generally used. 

In his fourth chapter, on the use of electricity in diagnosis, our author quotes 
the opposing views of Dr. Marshall Hall and Dr. Todd, as to the influence of 
cerebral disease upon the degree of irritability of the muscles ; he coincides 
with Dr. Todd in the opinion that in this respect cases of paralysis may be 
divided into three classes : — 

" i. If the excitability of the muscles — or rather the polarity of the motor 
nerves — be increased in the paralyzed limb, the case is one of cerebral paralysis, 
connected with an irritative lesion within the cranium. 

" 2. If the excitability of the muscles be nearly or totally lost, we have in all 
probability either lead palsy or traumatic paralysis; but it must be kept in 
mind that certain hysterical and rheumatic palsies of long standing present the 
same peculiarity ; and that it also may be found in cases of disease of the brain 
and the cord. 

" 3. If paralyzed muscles respond readily to the electric current, there is no 
lead in the system, nor is the. connection between the motor nerves of the para- 
lyzed muscles and the cord interrupted ; but if such cases are of long standing, 
they are due to brain disease; and if they are of recent standing, they are gene- 
rally instances of hysterical, rheumatic, or spontaneous paralysis." 

Chapter V., on the therapeutical uses of electricity, is, for obvious reasons, 
the most important one in this work. 

The medical employment of this remedy is chiefly for the relief of affections 
of the nervous system — loss of power, spasm, neuralgia, and anaesthesia. But, 
as Dr. Althaus remarks, these conditions are merely symptoms, capable of being 
produced by widely different disorders ; and their causes must be carefully made 
out before electricity is resorted to. 

As might reasonably be expected, cases of paralysis from intra-cranial disease 
are not very often amenable to electricity, which promises much more, we are 
told, in " cases of hysterical paralysis, rheumatic paralysis, lead palsy, incom- 
plete paraly&is of the lower extremities, connected with disease of the urinary 
organs ; cases of paralysis remaining after acute diseases, such as typhus, cho- 
lera, and cases of spontaneous paralysis, in which it is impossible to distinguish 
the cause of the lesion. Finally, cases of perverted nutrition and atrophy of 
the muscular substance are almost always beneficially affected by the application 
of electricity." 

Cases of paralysis from brain disease may, as pointed out by Dr. Todd, be 
divided into three classes, according to the state of the muscles of the part or 
parts affected. If these be relaxed and non-resistant, a carefully localized 
application of electricity may have a good effect. If there is rigidity, coming 
on at the outset, interference in this way would be useless. If, however, the 
rigidity succeeds a period of wasting and relaxation, there are cases in which 
the antagonist muscles may be electrically excited with advantage. 

Various local palsies are enumerated by Dr. Althaus as likely to be benefited 
by electricity. The muscles of the eye, and those supplied by the facial nerve, 
may have their function restored in this way. Hysterical aphonia seems to have 
yielded readily to Faradization. Wasting palsy, hopeless under any other form 
of local treatment, may perhaps be arrested, or even corrected, by the judicious 
and persevering use of electricity. Intestinal atony, and paralysis of the bladder, 
when not due to any cerebral or spinal lesion, may in like manner be obviated. 
Dr. Althaus states that he has relieved cases of amenorrhcea by means of elec- 
tricity, and quotes the similar experience of Golding Bird, Duchenne, and others ; 
Becquerel, however, did not find it effective in a single instance. We are inclined 
to object to this merging together of all cases in which the catamenia are want- 
ing, in view of the purely symptomatic character of this circumstance ; perhaps 
there is no abnormal phenomenon which needs to be more carefully traced back 
to its source than this, in order to a judicious choice of treatment. 



212 



Bibliographical Notices. 



[July 



Among spasmodic affections, chorea and writer's cramp are mentioned by our 
author as having been relieved by electricity, which he thinks might also prove 
beneficial in this form of wry-neck, in tetanus, and in hysterical cramps. 

Anaesthesia, as regards either special or general sensibility, is amenable to 
improvement in various degrees under the use of electricity. When of a hys- 
terical form. Dr. Althaus regards it as speedily curable by this agent, which is 
also very valuable in many cases of insensibility from poisoning. 

Neuralgia, when caused by wounds or structural lesions of the nerves, of the 
passages through which their course lies, or of important organs, affords hardly 
any chance for the successful operation of electricity. When, however, it seems 
to be a mere morbid exaltation of sensibility, or is of a rheumatic character, 
Faradization may be resorted to with advantage. 

In regard to the surgical uses of electricity, we think Dr. Althaus speaks a 
good deal in the manner of a medical theorist. Perhaps more is to be looked for 
in this way in the treatment of aneurisms and varices than in any other depart- 
ment of practice, unless it be in the prevention and cure of bed-sores. The time 
may come when lithotomy and lithotrity are superseded by the galvano-electric 
current, but the results hitherto attained have not been such as to indicate its 
near approach ; nor do we think that the actual cautery is any less painful when 
the source of the heat is changed. From the past history of surgery, as well as 
from the practical experience of the present day, we may learn that the utmost 
caution is to be maintained in abandoning principles and methods which have 
been already tested with success, for those which merely hold out brilliant hopes. 
As a general rule, the simpler the means used the better ; we cannot do away 
with the elements of uncertainty in the material upon which we have to work, 
but we can narrow them down in the appliances to which we resort. 

The little volume which has now been discussed will undoubtedly be of great 
service to medical men. To those who simply wish to employ electricity in 
exceptional cases, it will afford an excellent manual ; to those who are desirous 
of pushing their investigations further, it supplies abundant references to the 
literature of the subject, as well as a clear exposition of its fundamental prin- 
ciples. J. H. P. 



Art. XXIX. — Proceedings of the American Pharmaceutical Association, at the 
Eighth Annual Meeting, held in Boston, Mass., September, 1859, with the 
Constitution and Roll of Members. Boston : Press of Geo. C. Band & Avery, 
3 Cornhill, 1859. 

This is the eighth exposition of the annual labours of an institution now per- 
manently organized and placed upon a successful basis of operation. In the 
year 1852 the pharmaceutists of the United States, following the example of 
their medical colabourers for the public weal, determined to co-ordinate their 
efforts, with the view of advancing the science under their especial cultivation ; 
of promoting harmony and good feeling among those whose interests were simi- 
lar ; of correcting abuses which have hung over the occupation of dispensing 
and vending medicines, and of securing generally the elevation and prosperity 
of the profession of pharmacy. In this enterprise they have been eminently 
successful, and, judging from the last and the present annual record of their 
proceedings, seem to be becoming more enthusiastic and effective each succeeding 
meeting. They have demonstrated effectively that in union there is strength, 
and that it is only necessary to continue their useful undertaking to secure the 
highest respect and commendation from the community. With the view of 
pointing out the scope and the utility of the labours of our pharmaceutical co- 
operatives, we shall devote what space is at command to the examination of the 
present volume of proceedings. 

The volume is printed in handsome style, and consists of 416 pages, com- 
mencing with a report of their minutes. From these we learn that the meeting 
at Boston, as heretofore, was well attended ; fifty-five members having been 



I860.] 



American Pharmaceutical Association. 



213 



present, among whom we recognize the most respectable and accomplished 
druggists and apothecaries of the country. It may be stated that the delegations 
are composed of representatives of the pharmaceutical colleges and associations 
of the principal cities of the Union ; but additionally to these, in order to give 
this body a more extended influence, the plan of permanent membership has 
been adopted, which brings into active co-operation a very large number of 
efficient individuals. 

As is usual with such associations, the regular business was preceded by an 
appropriate address from the retiring president, and a similar one from his suc- 
cessor, when regular business matters were entered upon. Throughout the 
minutes we notice interesting matters which are there described in connection 
with each day's business, among which are communications from the Patent 
Office with reference to the introduction of seeds and the success in growing plants 
belonging to the materia medica. In looking over the list of subjects, either 
reported upon or submitted with this intention, we have been impressed with 
the highly practical nature of the inquiries which have occupied the attention 
of the association. There is one feature in these minutes that must strike forci- 
bly one who has noticed the wranglings and waste of time upon points of order 
on abstract questions so common in public meetings, and that is the directness 
with which subjects can be met and disposed of by practical men of business, 
whose interests are involved in coming to their conclusions, and whose minds 
are well balanced upon all issues of utility. In fact the debates and business- 
like tact exhibited by this association may afford a useful lesson to more pre- 
tentious conferences. The main substance of the volume is made up of reports, 
and we may be permitted to give of these a passing notice, commencing with the 
" Keport of the Committee on the progress of Pharmacy," which is an interesting 
summary of subjects and articles which have been brought forward within the 
year, both abroad and at home. It includes practical pharmacy and chemistry. 

The next subject reported upon is "Pharmaceutical Associations and Educa- 
tion," in which the facilities of instruction in pharmacy and the kindred associate 
branches are set forth. It commences with a reference to the oldest and for a 
long time the only College of Pharmacy in the United States, namely, that of 
Philadelphia, which, like the school of medicine of this city, may be termed the 
parent school. It appears from this report that there are now seven colleges of 
pharmacy in this country, besides the one alluded to : one in New York, one in 
Baltimore, one in Boston, one in Cincinnati, one in Richmond, and one in Chi- 
cago ; while a pharmaceutical association has been formed in Washington, and 
one in San Francisco. These are primary associations, which, from the experi- 
ence of the results in Philadelphia, have had a beneficial effect upon the profes- 
sion. Three of the associations enumerated have established schools, which are 
spreading their advantages through the community. In connection with this 
report is an exposition of the additions made during the past year to what is 
specifically designated "Pharmaceutical Literature," some remarks on the 
" Drug Market and Manufactures," and a Necrology. 

The next report is from the committee on " Weights and Measures." This is 
one of the most difficult subjects falling within the range of pharmacy. The 
report is from the pen of Alfred B. Taylor, of Philadelphia, who has most indus- 
triously and learnedly gone over the whole ground, presenting the most elaborate 
treatise upon weights and measures published in this country since the work of 
the late John Q. Adams, when Secretary of State. The labour of this report 
has been immense, and entitles the author to the highest commendation. The 
system of weights and measures has grown up with the progress of mankind, 
and complicated as it may be, is interwoven with the habits and usages of man : 
it, in fact, is part and parcel of his social existence. An exact, and at the same 
time simple and convenient mode of weighing and measuring has from time 
immemorial been sought for by rulers and governments ; but custom and long 
established habit has proved an obstacle to theoretical perfection. So far the 
effort has proved Utopian, and it may be asked at the present time whether any 
real advance has been made in this direction. To break in upon the usages of 
exchange and commerce is no easy task ; and we are of opinion that those who 
are enthusiastic in the matter, and who desire some modification of existing 



214 



Bibliographical Notices. 



[July 



standards, are doomed to disappointment. The decimal system, which has been 
so much lauded, and which recommends itself from its foundation in high mathe- 
matical science, and its simplicity, as it has been introduced in France, has not 
found universal favour, and has not supplanted the old weights in use by the 
general population, with whom they have been consecrated by habit. The ques- 
tion of weights in England and this country turns upon the employment of but 
one weight in pharmacy, and the tendency in the first is to substitute the Avoir- 
dupois for Troy, to make it in every respect suitable for use. The convention 
which met recently at Washington, for the revision of the United States Phar- 
macopoeia, determined that it was inexpedient at present to meddle with this 
portion of the work. What the New British Pharmacopoeia Commission will 
do in the premises remains to be seen. So far as we are concerned in the pre- 
sent revision, the maxim is a good one, "to let well alone." 

The next report is upon the " Revision of the Pharmacopoeia." Ever since 
the association of the pharmaceutical profession with the medical, in the revision 
of the Pharmacopoeia, assistance of an important nature has been rendered by 
the practical working members of the former. They have borne a large propor- 
tion of the burden of experimenting, and devising efficient means of arriving at 
positive results. These have been freely and liberally communicated, and we 
could point to many zealous pharmaceutists whose labours have been of great 
value in furthering the accomplishment of the work. The report before us is a 
continuation of labours commencing and set forth in previous years, not only 
in the proceedings of this association, but in the journals of pharmacy. It will 
be of great service to the committee of revision, who can cull from it many 
important recommendations, as well as hints and information for the successful 
issue of their undertaking. 

" Home Adulterations" is the title of the next report, and here we trench 
upon a subject that has occupied much attention on the part of both professions. 
The report is full of useful matter, well worthy of perusal, derived not only from 
authorities on this subject, but from special examination of articles, which were 
submitted in proof to the meeting. As the practice of adulteration is a foul blot 
upon trade, and as the cupidity and wickedness of dealers cannot be brought 
under subjection, either to law or conscience, the only plan is a full exposition 
of the means of detection, and to this the committee has, as far as possible, 
devoted itself. 

We find in connection with these reports, which are general and intrusted to 
committees, some valuable ones on detached subjects. One on " Fluid Extracts," 
by Mr. Wm. Procter, is so full as almost to exhaust the subject. There are also 
some essays which are valuable additions, among which may be specified one 
on the " Therapeutic Yalue of Foreign and Indigenous Medicinal Plants," by H. 
A. Tilden ; and another " On the Mercurial Compounds prepared with a New 
Mercurial Machine," by Dr. Edward R. Squibb. 

We cannot conclude this notice without expressing our great pleasure in 
possessing this contribution to "pharmaceutic literature," from the body of 
intelligent and highly scientific gentlemen who compose the association, and at 
the same time venture to predict that a continuance in future years of such 
praiseworthy efforts will maintain that reputation for practical and scientific 
pharmacy, which the profession in this country now holds, deservedly, in foreign 
lands. J. C. 



Art. XXX. — Food for Babes; or Artificial Human Milk, and the Manner of 
Preparing it and Administering it to Young Children. By William Henry 
Cumming, M. D. 12mo. pp. 100. New York, Anson D. F. Randolph, 1859. 

There can be no doubt that a large proportion of the disease and mortality 
which occurs among infants is due to errors committed in respect to their diet — 
and it is not less certain that many of these errors are not merely the result of 
ignorance or carelessness on the part of mothers and nurses, but of erroneous 



I860.] 



Gumming, Food for Babes. 



215 



views inculcated by physicians in respect to the nature of the aliment adapted 
for the due sustenance of the system during infancy, and for the supply of ma- 
terials adapted for its proper development and growth. 

That the breast-milk of the mother — when she is healthy, well nourished on 
wholesome food, and in the practice of regular and sufficient active exercise, out 
of doors in a dry, wholesome atmosphere — is the only proper food for the infant, 
during the first months of its existence, is a truth that is taught us by Nature 
herself; and that to this food, should the infant be confined mainly if not en- 
tirely, for the first twelve months, at least, of its existence is not less clearly 
indicated by the lessons of experience and by the teachings of physiology. 

The important question, however, is as to the food which is best adapted to 
supply the place of the maternal milk when, from any cause, the infant is neces- 
sarily deprived of this, and there is no possibility of furnishing it with nourish- 
ment from the breast of a healthy nurse. It is evident of course that that food 
is the best for an infant thus circumstanced which approaches the nearest, in its 
form and composition, to the breast-milk of the mother. Upon no other kind 
of food can healthy vigorous children be reared. Much of the bowel complaint, 
marasmus, and slow wasting disease, so common during the first period of ex- 
istence is due to either an attempt on the part of mothers to substitute some 
other nourishment for the maternal breast, or to make up for a real or supposed 
deficiency in the supply of nourishment from the latter, or to compensate for 
its defective quality by a farinaceous diet, with or without milk, or one of an 
equally improper character. 

In the little work before us, Dr. Cumming discusses with no little ability the 
subject of the proper diet for infants — more especially the one best adapted for 
their adequate nourishment in those cases in which there exists a necessity for 
their being reared without the breast. 

Viewing the embryo from the period of conception, he shows the dependence 
of the newly developed being, from the moment of its existence to the close of 
its nine months sojourn in the womb, upon the blood of the mother, and its 
almost equally intimate dependence on her milk for many months after its birth : 
and, consequently the vast importance to the existence of man, during his fcetal 
and infantine stages of existence — to his full and symmetrical development — to his 
freedom from suffering and disease, that the blood and milk of the mother should 
be ample in quantity and pure in quality. 

Nearly all the general principles advanced by Dr. C, and the major portion 
of his practical deductions from them, are perfectly correct. It is true, that 
we do not see the good that would result from strictly carrying out in practice 
the proposition of the author to confine the diet of the infant exclusively to that 
derived from the breast of the mother during the first eighteen or twenty-four 
months of its existence. On the contrary, we should in very many cases, antici- 
pate injury to both mother and child were the practice invariably pursued. A 
robust, well developed infant may with perfect safety be taken from the breast, 
and placed upon a diet composed of some wholesome food, when one year old, 
while it is proper, in the case of puny, slowly developed infants, to continue 
them at the freely secreting breast of a healthy mother or nurse for a few months 
longer. 

The so-called "artificial human milk" which Dr. C. recommends as a substi- 
tute for that of the mother, when this entirely fails — or in connection with it, 
when deficient in quantity — is obtained in two ways. The first, is by taking the 
upper third of a portion of cow's milk that has stood for four or five hours. 
This will be found to contain about fifty per cent, more butter than the ordinary 
run of cow's milk. To obtain one quart of this milk, three quarts of milk are to 
be set aside, and at the end of four or five hours the upper quart is to be care- 
fully removed for use. The other way, and the one to be preferred in hot weather 
is to take milk from the latter half of that given by the cow at one milking, which 
contains double the amount of butter the produce of the first half of the milking 
does. If the cow gives eight quarts at a milking, the milk for use should be 
taken from the last four quarts obtained. It is of course understood the milk 
is to be that of a young, healthy, vigorous, well-fed animal, with a calf between 
two weeks and five months old. 



216 



Bibliographical Notices. 



[July 



The milk thus obtained when diluted with 1£ parts of water, and properly 
sweetened, Dr. 0. believes to resemble in its composition most closely the na- 
tural secretion of the breasts in vigorous, healthy and properly nourished fe- 
males. 

That this " artificial human milk," as it is termed by the author, affords a very 
admirable article of nourishment to replace that which nature provides for the 
infant in the maternal breast, we have not the slightest doubt. Dr. Cumming 
has ascertained from ample experience that it presents to the child in the form 
best adapted for the action of its digestive organs, all the materials it needs for 
growth, development, warmth and activity. 

We would suggest that the analysis of human milk given by Dr. C. differs 
very essentially from the analyses of Vernois and Becquerel, of L'Heretiere and 
of Simon. From the analysis of the latter especially, it would appear that the 
amount of casein is at its minimum at the commencement of lactation, and 
gradually increases up to a certain point, when it attains nearly a fixed propor- 
tion ; that the amount of sugar is at its maximum at the commencement and 
subsequently diminishes, while the butter in respect to quantity is a very vari- 
able constituent of the milk. D. F. C. 



Art. XXXI. — Tlie Institutes of Medicine. By Martyn Paine, M. D., Profes- 
sor of the Institutes of Medicine and Materia Medica in the University of the 
City of New York, etc. etc. etc. Fifth edition, 8vo. pp. 1109. New York : 
Harper & Brothers, 1859. 

That a fifth edition of Dr. Paine's work should have been called for shows, we 
conceive, a healthful state of mind among the reading portion of the medical 
profession in this country. They who make it a duty to read and digest works 
of this class will not be satisfied with the meagre aliment to be derived from 
compounds and manuals. The work of Dr. Paine is no superficial digest of 
popular doctrines of physiology, pathology, and therapeutics, in reference to the 
human organism, but a philosophical exposition of the Institutes of Medicine, 
based upon well authenticated and correctly translated facts and observations. 
It is not merely an exposition of what others have believed and taught, but a 
methodical system of the philosophy of medicine, deduced by the author from 
what is known in respect to the vital and physical laws and functions of the 
living organism in health, and the rich fund of instruction acquired from the 
cautious observation of disease in its onset, phenomena, progress, and results, 
and from the empirical study of the effects of remedial agents at the bedside of 
the sick. 

The institutes of medicine by Dr. Paine present an unquestionable claim to 
the title of originality. Out of the materials furnished by the medical observers 
of all times and all places, the author has constructed an edifice of his own ; 
one, upon the whole, well adapted for the purposes to which it is dedicated. 
Although we are persuaded that, upon a close examination, many defects may 
be discovered in different portions of it, we still cannot but admit the solidity 
of its foundation, and admire the symmetry and skill exhibited in its general 
plan and execution. 

The present is simply a revised reprint of the fourth edition, with the addi- 
tion of a Supplement, embracing certain recent observations, which the author 
believes to be corroborative of some of the principal views taught by him in 
the body of the work. D. F. C. 



I860.] 



217 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. Observations on Digestion, made on a Case of Fistulous Opening into the 
Small Intestine. — Prof. Busch, of Bonn, has availed himself of the opportunity 
afforded by a case in which a fistulous opening into the intestine existed, of 
studying several points in regard to the physiology of the digestive process. 

A woman, aged 31, in the sixth month of her fourth pregnancy, was tossed by 
a bull, one of whose horns lacerated the abdominal wall. At first there seemed 
to be no injury of the intestine ; but at the end of three days a perforation ap- 
peared, resulting in the establishment of an opening through which food escaped. 
In six weeks the woman, although she ate much, had become extremely emaciated 
and weak. She was then taken to Bonn. Between the umbilicus and the pubes 
there was an aperture in the abdominal walls more than an inch and one-fifth in 
length, the bottom of which was formed by the posterior wall of the intestine ; 
the upper and lower ends of the intestine were represented by two orifices at the 
angles of the wound. The position of the wound, the size of the intestine, the 
existence of valvulse conniventes in large number, the fluidity of the chymous 
material which exuded from the upper end, and its grass-green aspect, led to the 
inference that the injury had affected the upper third of the small intestine. 
Nothing whatever passed from the upper to the lower opening, and several 
attempts to establish a communication proved fruitless. The patient was allowed 
to eat as much as she wished ; but as this was not sufficient, food — principally 
protein, as soups, eggs, etc. — was thrown into the lower opening ; frequently, 
also, pieces of cooked eggs and meat were thrust into it by the ringer. Her 
general health improved under this treatment, and after a time the supply which 
she received by the stomach was sufficient. 

Hunger. — The patient at first had a most voracious appetite ; she never felt 
satisfied. She continued to eat, even when the first portions of food which she 
had taken were escaping through the opening. She then would say that she 
felt better, but was still hungry. Prof. Busch infers that hunger is composed 
of two separate sensations — one general, the other local; the former resulting 
from the want of material to repair the waste of tissue. 

Movements of the Intestine. — The bottom of the opening was formed of a long 
portion of the posterior wall of the intestine, the anterior wall having been de- 
stroyed by gangrene ; there was also a large ventral hernia, the coverings of 
which were so thin that the least modification in the size of the intestine was as 
clearly perceived as if it had been laid bare. During the ordinary peristaltic 
movements it was not possible to observe any difference between those which 
took place in the portion of intestine covered by skin and in that which was 
exposed to the air. When, on the other hand, the upper part of the intestine 
became invaginated in the opening, this portion contracted much more actively, 



218 



Progress or the Medical Sciences. 



and was sometimes the seat of a tonic contraction, which stiffened and raised it 
like a solid body. 

The intestinal movements were not continuous ; there were often intervals of 
complete rest during more than a quarter of an hour. During these intervals 
neither exposure of the part to the temperature of the room, nor the careful 
introduction of the finger, would excite peristaltic action ; even the taking of 
food would not excite it at once. There was no regularity in these intervals of 
action and rest, except during part of the night. Up to 10 or 11 P. M. there 
was a flow of chymous material or of liquids from the upper end of the intestine, 
so that, at first, the patient was always wet, in spite of all care. No discharge 
then took place until 4 or 5 o'clock in the morning. When she made a hearty 
supper, a part escaped at once, but the rest remained in the digestive canal until 
the next morning. This pause in the intestinal action did not arise from sleep, 
for it was observed when the patient lay awake at night ; and the matters escaped 
in the daytime while she slept as well as when she was awake. 

The escape of the matters contained in the intestine was not continuous, but 
jerking; and a propulsive movement of the intestine was even observed in the 
neighbourhood of the opening. It is possible, however, that this was only the 
result of the adhesion of the intestines to the abdominal wall, which furnished a 
point oVappui. 

Eeversed peristaltic movements existed, and frequently impeded the experi- 
ments. Thus the aliments introduced into the lower opening of the intestine 
were often rejected after some hours, and fatty matters even after some days. 

Observations on the Lower End of the Intestine. Hie Intestinal Juice. — 
As the lower end of the intestine received nothing whatever from the upper end, 
it was possible to study in it the intestinal secretion in its pure state. The 
quantity of this, in the physiological condition, was not great. On introducing 
a bivalve speculum, the intestinal mucus could be plainly seen between the 
valves ; it was white, or of a very slight rose tint. Sugar, tied up in a net bag, 
and introduced into the intestine, was not completely dissolved in a quarter of 
an hour. Under pathological irritation, the quantity of juice was increased; 
this was ascertained on two occasions. It was then thick and consistent. The 
reaction was always alkaline. The quantity of solid matter contained in it varied, 
according to numerous observations, from 7.4 to 3.87 per cent., the mean being 
5.47 per cent. 

Digestive Action oftlie Intestinal Juice. — The digestive property of the intes- 
tinal juice has been denied by some, while others have, correctly, admitted it. 
At the commencement of the treatment the state of the patient began to be 
improved only when she was fed through the lower opening of the intestine. 
Into this were introduced soup, beer, gruel, hard eggs, and meat cut into small 
pieces. During the six weeks previous to her entrance into the hospital the 
woman had only two small, hard stools. After being fed in the way above de- 
scribed, she had at first an abundant evacuation every twenty-four hours ; but 
later it became necessary to use enemata. The evacuations resembled ordinary 
fecal matter in form and consistence ; but the colour was grayish white, and they 
emitted a repulsive putrid odour. No portions of egg nor of meat were found 
in them. 

In order to study the digestive action of the intestinal juice on different foods, 
a weighed portion of food was inclosed in a net bag, and introduced into the 
intestine through a speculum. To ascertain the quantity dissolved, the loss of 
solid matter was sought. For this purpose a known quantity of the same food 
was dried, and the- amount of solid matter estimated; from which, on drying at 
the same temperature the portion removed in the bag, it was easy to calculate 
the loss which the latter had sustained. 

Protein Matters. — Coagulated albumen and cooked meat always lost sub- 
stance, and the morsels, when drawn out, presented traces of decomposition. 
The angles of the cubes of albumen were rounded, and the surface had a cheesy 
aspect, and peeled off in grumous masses when washed with water ; the meat 
was flabby, soft, and pale. The masses had a penetrating putrefactive odour ; 
and the presence of hydrochloric acid evolved ammoniacal vapour. This was 
not the result of ordinary putrefaction from moist heat ; for none of the experi- 



I860.] 



Anatomy and Physiology. 



219 



ments lasted above seven hours, and decomposition commenced at an early 
period. The cause can only be sought for in a peculiar ferment furnished by the 
intestinal juice. Of albumen, the percentage quantity digested varied from 35.35 
in six hours and a half to 6.5 in five hours and a quarter; that of meat varied 
from 29.9 in seven hours to 5.5 in five hours. 

Starch and Sugar. — Starch, dried at 212°, was introduced. The percentage 
loss varied between 63.53 in five hours and a half, and 38.5 in six hours. After 
injecting a solution of starch into the lower end of the intestine, the stools were 
found to contain neither starch nor sugar, but only traces of dextrin. The 
starch underwent conversion into grape-sugar, which was always found in the 
bag. Cane-sugar was not changed into grape-sugar ; a large portion was found 
in the feces in the state of cane-sugar, and the urine contained no trace of it. * 

Fats. — These were submitted to experiment on two occasions. On the first, 
more than three ounces (avoirdupois) of melted butter were introduced, in small 
portions, into the intestine. After ten days the patient spontaneously had a 
white very fetid stool, of the consistence of boutllie. On being examined, after 
cooling, it was found to be covered by a layer of solid fat; the subjacent portion, 
under the microscope, appeared chiefly composed of large fat-drops and fat- 
crystals, mixed with epithelial cells. The evacuation had an acid reaction, and 
the vessel in which it had been treated by ether evolved an odour of butyric 
acid. A little more than one-sixth of the quantity of fatty matter administered 
was found. A large portion, however, of the butter had been expelled from the 
intestine by reversed peristaltic movements, so that probably little or none of it 
was absorbed. The second experiment, which was made at the end of a fortnight, 
with cod-liver oil, gave precisely the same result. 

Observations ox the Upper End of the Intestine. — Alimentary matters, 
contrary to the general supposition, did not remain long in the stomach. In 
the morning, when the intestine was empty, the peristaltic movements expelled 
frothy mucus. On giving food which could be readily recognized, the first por- 
tions appeared at the opening in about a quarter or half an hour ; and, after a 
copious meal, three or four hours were sufficient for the expulsion of the whole. 

The reaction of the mixture of digestive fluids, expelled in the fasting state, 
was almost always neutral, rarely faintly acid or alkaline. The intestinal juice, 
when carefully washed from the fistulous opening, was constantly found to be 
alkaline. After a meal, the chymous mass gave very variable reactions ; at first 
protein compounds seemed to produce an alkaline or neutral liquid, while fat, 
starch, and sugar gave an acid one ; but repeated observations showed so great 
variations in these respects, that no fixed result could be arrived at. 

The solid aliments contained in the chyme did not appear much changed on 
simple inspection; but on touching the surface of coagulated albumen and pieces 
of meat, they were found to be more friable than in the fresh state. The muscu- 
lar fibres of meat were divided both longitudinally and transversely, as is already 
known to be the case ; and this was observed more when the meat had been very 
finely cut up. These solid alimentary matters floated in a large quantity of 
biliary fluid ; but after the eating of large quantities of cabbage, turnips, and 
potatoes, a small layer of liquid separated only after the mixture had been 
allowed to rest a considerable time. Whenever the diet during the day was con- 
fined to a single article of food, the chymous mass was more consistent towards 
the evening than in the morning ; while after a variety of food the quantity of 
liquid was the same at different hours. 

After the injection of feculent food, the chyme contained a large amount of 
starch and sugar ; while after cooked protein compounds a slight turbidity was 
very rarely produced on boiling the liquid. 

The digestive fluids were rejected in such a mixed state, that no definite result 
could be derived from their examination. The absence of indications of the 
presence of sulphocyanide of potassium showed that saliva was not present. 
Besides bile and pancreatic juice, there must have been a large amount of fluid 
supplied by the stomach, for the total sum of solid matters was very small ; the 
average was 2.48 per cent., the extremes 2.56 and 2.34. This is remarkable, 
since in man the gastric juice itself gives 3 per cent, of solid residue. 

Cane-Sugar. — After having ascertained that the fluids passed from the opening 



220 



Progress of the Medical Sciences. 



[July 



in the morning, when the patient had been confined to an exclusively animal diet 
on the preceding day, gave no reaction with the potash and copper test, she was 
made to take, fasting, solutions of cane-sugar. In the fluid which escaped, only 
a small part of the sugar was found — as grape-sugar, never as cane-sugar. This 
observation confirms the opinion of M. Bouchardat. 

Raw Albumen. — In the morning, the albumen of four eggs, beaten up with a 
little water, was given to the patient. After four hours there was collected a 
moderately large quantity of an alkaline liquid, thready, mixed with bile, and 
containing no coagulated albumen. If the gastric juice had solidified this sub- 
stance, portions of it would have been found. The quantity of albumen excreted 
was found to be 36 per cent, of the amount taken in. 

Gum Arabic underwent no change, and escaped almost entire from the opening. 

Gelatin. — Of this substance nearly two-thirds were absorbed; the remaining 
third, which escaped, had the ordinary chemical characters, except that it did 
not gelatinize, and that its warmed solution was rendered turbid by acetic acid. 

Milk. — After milk had been taken, an acid liquid escaped, in which the casein 
had been coagulated by the acids of the stomach, not in large masses, but in 
fine particles. The filtered liquid contained a portion of uncoagulated casein. 

Fats. — A large dose of cod-liver oil was given to the patient in the morning, 
and on each occasion the quantity of liquor that escaped was relatively very 
large. Its reaction varied ; most frequently it was acid, rarely alkaline. In the 
latter case the fat was so finely divided that it could not be recognized by the 
naked eye ; but under the microscope oil-globules were found in the molecular 
state. When the reaction was acid, the greatest part of the fat formed a similar 
emulsion, but on the top there floated a smaller quantity of oil, in large drops. 
When the alkaline emulsion had been kept during twenty-four hours, it became 
acid, and a part of the oil floated on it in large drops. 

Digestibility of certain Articles of Food. — Prof. Busch endeavoured to obtain 
information on this subject by examining the quantity of ingested aliment which 
arrived at the opening in the upper part of the intestine. In one experiment, 
in which two ounces of sugar were taken, only one-thirtieth part reappeared ; in 
another, in which three ounces were taken, one-fifteenth was found. Of albumen, 
the proportion of the quantity absorbed to that found in the discharged chyme 
was as 7 to 4 ; of gelatin, almost as 2 to 1. 

Prof. Busch has drawn up a table which shows the proportion between the 
weight of the material ingested and that of the chyme thrown out. 



Food taken. Chyme. 

Fat ........ 1 6 

Gelatin 1 3.675 

Boiled eggs 1 2.73 

Meat 1 1.73 

Milk 1 1.25 

Turnips 1 1.2 

Cabbage . ' .1 0.91 

Potato-soup 1 0.7 



With regard to the latter two articles, the quantity of juices secreted is too 
small to make up for the loss caused by absorption into the stomach and the 
commencement of the small intestine ; while fat and gelatin give rise to a con- 
siderable secretion of fluid. 

In examining the relation between the quantity of solid matter taken in and 
that found in the chymous mass, the loss representing the quantity absorbed, 



the following results were arrived at : — 

Solid matter Solid matter 

taken in. rejected. 

Gelatin ........ 1 0.94 

Boiled eggs 1 0.76 

Milk 1 0.62 

Cabbage 1 0.58 

Potato-soup 1 0.53 

Turnips . 1 0.49 

Meat 1 0.35 



I860.] 



Anatomy and Physiology. 



221 



Although these numbers cannot be supposed to possess an exact mathematical 
value, they nevertheless afford important instruction. 

Two experiments were made during- periods of twenty-four hours ; once with a 
varied animal diet, and at the other time with a mixed animal and vegetable diet. 
As far as the results of these experiments showed, the amount of matter absorbed 
from the mixed diet was about ten times as great as that absorbed from the 
purely animal diet. While the patient was taking the animal diet, the matters 
which escaped from the opening consisted at first (as always) of a liquid in 
which floated fragments of meat and of egg ; gradually, however, the quantity of 
fluid diminished, the mass became more consistent, and at last, especially on the 
following morning, there escaped a mass having the appearance and smell of 
pure fresh meat, not coloured by bile. Under a mixed diet, the chyme preserved 
its liquid consistence throughout, except in the middle of the day, when it became 
more consistent after the patient had taken some legumes at dinner. 

Digestive Properties of the Fluids discharged from the Small Intestine. — In 
the course of his researches, Prof. Busch observed that the liquid which escaped 
from the opening, especially after the ingestion of protein aliments, passed very 
slowly through the filter, and that the fragments of meat and egg continued to 
diminish in size while lying on the filter, so that at the end of the operation small 
portions only of solid matter were left. This proved that the digestive influence 
of the mixture of gastric, pancreatic, and intestinal juices, and bile, was exerted 
on the protein compounds from the commencement of the small intestine ; and 
this occurred, whatever was the reaction of the fluid. But the aliments had been 
in contact with pure gastric juice in the stomach ; it was therefore interesting to 
ascertain whether the mixture of digestive juices possessed equal power on food 
plunged directly into it. Experiment on this point showed that coagulated 
albumen and roast veal, placed for a period varying from six to eight hours, at a 
low temperature, in contact with the alkaline fluid which escaped from the fistula 
after the ingestion of fluid albumen or of meat, lost a small quantity of solid 
matter, and were slightly disintegrated. But this action was incomparably less 
than that which was exerted by the mixed juices on matters which had been sub- 
mitted to the action of pure gastric juice. It follows from this that alimentary 
matters leave the stomach while imperfectly digested, and that their digestion 
is performed in great part in the intestines. — British Medical Journal, April 7, 
from Archiv far patholoqische Anatomie unci Physiologie, Bd. xiv., and L' Union 
Medicate, March 15 and 20, 1860. 

2. Structure of the Cerebrospinal Capillaries. — M. C. Robix considers at 
length two anatomical conditions bearing on the phenomena of the cerebral cir- 
culation. These are, firstly, the disposition of the fibre-cells around the capil- 
laries ; and secondly, the existence of a special external enveloping sheath which 
they possess. 

The capillaries themselves he divides into three kinds, according to their cali- 
bre. The smallest kind varies in diameter, from that of a blood globule down- 
wards, is composed of a single homogeneous unfibrillated tunic, and is provided 
with longitudinally-placed nuclei. A larger variety possesses double walls, of 
which the inner one contains nuclei arranged longitudinally, whilst the outer 
one is entirely formed of fibre-cells containing nuclei with a transverse axis. 
The third and largest kind of capillary consists of three tunics — viz., of the two 
entering into the composition of the second variety of capillary, and of a third 
or adventitious one formed of longitudinal, parallel, and undulating fibrils. 

As respects the muscular or contractile nucleated fibres which abound as 
well in the capillaries of the pia mater, retina, and ciliary processes of the iris, 
as in those of the substance of the brain and spinal cord, they are so intimately 
adherent that the line of junction between them is generally undiscernible. 
They may, however, be well studied after macerating a portion of the tissue 
containing them for a few days in very dilute nitric acid (10 per cent.), by 
which, although the nuclei are rendered less visible, the line of juxtaposition 
of the fibre-cells become more visible. By this process they very frequently 
become quite isolated, falling off into the surrounding liquid, or are seen only 
partially removed, so as still to adhere slightly in a ring-like form not entirely 



222 



Progress of the Medical Sciences. 



[July 



surrounding the capillaries. In the third class, or largest sized capillaries, the 
addition of the acid will be found to have destroyed the striated appearance of 
the outermost membrane, and to have made it granular, but at the same time 
to have made the transversely-striped character of the fibre-cell tunic very 
apparent, and to have rendered the cells less regular and of a yellowish hue. 
When the fibre-cells have been isolated, the nuclei and the substance of the 
fibres are seen to have become homogeneous. 

Passing on to the consideration of the investing tunic or sheath of the capil- 
laries, Robin states that around a certain number of capillaries of the brain, 
spinal cord, ependyma, and pia mater, such a covering exists at some distance 
from the proper walls of the capillary, and that the space between the vessel 
and the tunic is occupied by a colourless liquid mixed with molecular granula- 
tions or small free spherical nuclei, about j^th of a millimetre in size, and 
varying in number in different parts, in some places being so abundant as quite 
to obscure the nuclei of the capillary. Almost always in persons above forty or 
forty-five years of age the space between the vessels and this outer sheath con- 
tains much fatty granular matter, and frequently large grains of amorphous 
haematosine, isolated or conjoined. This special sheath could not be traced in 
capillaries beyond a third of a millimetre in diameter ; but when in the smallest 
vessels it is found to commence, it is seen to be exquisitely delicate, and to be 
adherent to the capillary walls. The exact ending of the sheath towards the 
largest sized vessels could not be made out. This sheath is insoluble by acetic 
acid, devoid of nuclei or granulation, and quite transparent, being generally un- 
dulating at its margins. It follows the capillaries in all their anastomoses, and 
at a bifurcation is generally dilated. The spherical nuclei beneath the sheath 
range about ^^th of a millimetre in size, are finely granular, and insoluble in 
acetic acid. They bear a certain analogy to the leucocytes of lymphatics, and 
from their position, &c, particularly to those of the lymphatics which are found 
surrounding a part of the circumference of arteries in reptiles and Batrachise. 
Occasionally fatty granulations are seen floating between the above-named 
nuclei. — Med.-Chir. Rev., April, 1860, from Brown-Sequard's Journ. de la 
Phys., Oct. 1856. 

3. Experimental Inquiry into the Action of Alcohol on the Nervous System. 
— Dr. W. Marcet relates [Med. Times and Gaz., March 3 and 31, 1860) some 
experiments made by him to determine the action of alcohol on the nervous 
system. He gives the following conclusions as the results of his investiga- 
tions : — 

1. That alcohol acts through the circulation principally, though not exclu- 
sively, on the nervous centres by means of absorption. 

2. That alcohol exerts a slight but decided action on the nervous centres 
through the nerves, independently of the circulation. 

3. That the influence transmitted through the nerves may be of two kinds : — 
(a.) It may give rise to a shock, or temporary complete suspension of sensa- 
tion and of muscular motion (with the exception, perhaps, of that of the eyelids), 
although respiration continues. 

(b.) It may produce no other visible effect than shortening life. 



MATERIA MEDICA AND PHARMACY. 

4. New Application of Chloroform in Neuralgia and in certain Rheumatic 
Complaints. — Mr. Little made the following communication to the Medico- 
Chirurgical Society of Edinburgh. 

During my residence in Singapore, East Indies, I was at one time in the habit 
of using liquor ammonioe to produce an immediate blister, when instantaneous 
counter-irritation was thought necessary in certain cerebral affections, etc. — a 
piece of lint soaked in ammonia being applied to the part, and covered with oil- 



I860.] Materia Medica and Pharmacy. 223 

silk, when in a few minutes so much irritation was produced as to raise a blister. 
In administering chloroform to my patients, I noticed that their lips were often 
partially blistered by it ; and recollecting' the mode of using the ammonia, I 
thought of trying the chloroform in the same way, but found that neither oil- 
silk nor gutta percha tissue would answer. I then used a watch-glass to cover 
the lint soaked in it, and with the best effect. 

The manner of application is to take a piece of lint, a little less in size than 
the watch-glass to be used (which need not be more than two inches in dia- 
meter), to put it on the hollow side of the glass, to pour on it a few drops of 
chloroform sufficient to saturate it, and then to apply it at once to the part 
affected, keeping the edges of the glass closely applied to the skin by covering 
it with the hand, for the purpose of keeping it in position, as well as of assist- 
ing the evaporation of the chloroform. This may be done from five to ten 
minutes, according to the amount of irritation wished for. 

The patient during this time will complain of the gradual increase of a burn- 
ing sensation (not so severe as that produced by a mustard sinapism), which 
reaches its height in five minutes, and then abates, but does not entirely dis- 
appear for more than ten minutes. 

To insure the full operation of the remedy, it is necessary that the watch- 
glass be rather concave, that it be closely applied to the skin, and that the hand 
applied over it be sensibly warm. The immediate effect of the application is to 
remove all local pain in neuralgia, and relieve that of rheumatism. 

Its effects on the skin are at first a reddening of the cutis, which in some cases 
is followed by desquamation of the cuticle ; but this depends on the part to 
which it is applied, and also upon the susceptibility of the individual. In some 
cases, if the application has been prolonged, a dark brown" stain remains even 
for a week or ten days, the same effect as sometimes follows the use of a mus- 
tard sinapism. 

In Singapore I have used chloroform after this fashion in various neuralgias 
of the face, in inflammations of the eye and ear, in one case of angina pectoris, 
in several cases of neuralgia affecting the abdominal parietes, in lumbago, dys- 
menorrhcea, and in pain attending congestion of the ovary, etc. 

Personally, I can testify to its great efficacy in two severe attacks of rheu- 
matic inflammation of the eyes, in which the pain came on periodically about 
3 A. M., with such severity that I thought the loss of sight itself would be pre- 
ferable to its continuance. All other remedies, such as blisters, leeches, opium 
externally and internally, belladonna, etc., were of no avail in soothing the pain ; 
water almost boiling applied by a sponge giving only a little relief. I then 
thought of this use of chloroform, remembering how much it had benefited my 
patients in other similar affections. The first night, the application of it to the 
temple relieved the pain in ten minutes ; on its return the next night, the appli- 
cation again relieved it; and four times only was it required to remove com- 
pletely the local pain ; allowing, in the meantime, constitutional remedies to 
produce their effect. Since my return to this country I have recommended this 
remedy on several occasions to persons suffering from neuralgia of the face and 
head, and always with the same good effects as in India ; and the other evening 
one of my domestics was quickly and effectually relived by it of a painful spas- 
modic contraction of the platysma myoides muscle, which prevented her raising 
her head from her chest. The chloroform was applied as directed, with imme- 
diate benefit, and next morning she was quite well, though in previous attacks 
several days elapsed before relief was obtained. I have mentioned this method 
to several medical men of this city, who have found it of great benefit ; and that 
it may be more extensively known, is my reason for now bringing it before the 
profession. — Edinburgh Med. Journal, April, 1860. 

5. Cypress as a Remedy for Bruises. — Dr. Little states that during his long 
sojourn in the East, he had many opportunities of testing the efficacy of native 
medicines, one of which he thinks worthy of notice, and of being ranked as a 
household remedy. 

It is to the Chinese that he is indebted for the knowledge of the use of this 
plant — the Oupressus Chinensis. In severe bruises they use it both internally 



224 



Progress of the Medical Sciences. 



[July 



and externally. The latter method of applying it Dr. C. recommends to the 
profession as an excellent remedial agent in bruises and contusions ; and, if 
applied in time, it will prevent tumefaction and discoloration of the skin, and, 
sooner than any other application, restore the bruised tissues to a healthy 
condition. 

" The manner of using it is to bruise the young shoots into a paste with proof 
spirit or brandy, and then to apply it to the injured part. I have tried it ex- 
tensively in the East with invariable success, when used immediately after the 
receipt of the injury ; and in the case of one of my children I had an opportu- 
nity of applying it in this country, and with the same good result. I have only 
used the Cupressus Chinensis, or Chinese arbor vitse shrub, for this purpose, 
but have no doubt other species, as the G. Occidentalis, or American Cypress, 
and the G. Sempervirens, would answer equally well ; and as these plants grow 
in almost every shrubbery, the remedy is generally at hand." — Ibid. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

6. Treatment of Phthisis by Cod-liver Oil and TJva Ursi. — Dr. Henry 
Kennedy, in a communication to the Surgical Society of Ireland (March 10th, 
1860), spoke very highly of the power of cod-liver oil in phthisis. He said that 
of all the means at our disposal there is no^single remedy which approaches it 
in efficacy. " I have never seen," he states, " the pulse fall, the strength im- 
prove, the flesh increase, and the perspirations cease, from any other cause than 
the fish oil — I mean when phthisis is once established. Before that period, 
change of air and scene will do much ; but after it, I must repeat that the remedy 
appears to me quite secondary to the use of the oil : not that one should be used 
to the exclusion of the other, but that each should be estimated at its just value. 

" Whilst, however, I thus speak in favour of the oil, I would not, for a moment, 
put it forward as a panacea. It will, I know, often disappoint the practitioner. 
Nor is it to be expected that either it or any other remedy should be of universal 
application. There are some few points, however, connected with its use, which 
appear to me to require more consideration than, as far as I know, they have 
yet received, and by attention to which the oil may be given with better effect, 
and more generally than is even now done. To these points, then, I would at 
present direct attention. 

"I would begin by observing that in many phthisical cases it is necessary to 
prepare the patient for the oil. Simple and obvious as this rule appears, I have 
reasons for knowing that it is often neglected, and you may constantly hear cases 
spoken of where the oil is said not to have agreed, and to have been in conse- 
quence given up. Now I know as a matter of fact, that in the greater number 
of these cases a very little management would have enabled the patient to have 
taken the oil, and. in a medicine of such value, this is no trivial point to gain. 
But, it will be asked here, what preparation is necessary ? and, speaking gene- 
rally, the answer is, to avoid giving the oil when anything of real inflammatory 
action is present. All who are in the habit of watching phthisical patients must 
have observed the great tendency which exists to inflammatory attacks. In- 
deed, during the whole progress of a very large number of these cases, a kind of 
low inflammatory action is present, which is, however, very liable at times to 
become aggravated, and fits even of a mild kind of fever are by no means un- 
frequent. Now, under such circumstances, the fever must be lowered, and any 
inflammatory action lessened, before the oil is begun ; and I believe there is no 
better plan of accomplishing this than by the use, for a few days, of some one 
of the salts of potash. I have not been able to satisfy myself as to the com- 
parative value of these salts, but the bicarbonate, either in effervescence or 
plain, or the simple nitrate, will answer every purpose. In some cases, and, I 
would add, more generally than might at first sight be imagined, even small 



I860.] Medical Pathology and Therapeutics. 



225 



doses of tartar emetic prove of very great service. It does not seem to be com- 
monly known that this last medicine was long since specially recommended as a 
cure for phthisis, but it was at a period, before the use of the stethoscope had 
made the diagnosis of the disease as certain as it now is. It is going too far. 
however, to put it forward as a cure for phthisis ; but, under the circumstances 
I am now speaking of, and in cases which are suited for it, it gives valuable 
assistance, as probably many present are quite aware. In other instances, again, 
potash may be combined with the oil itself, as in the form of the liquor potassse, 
of which one or two drachms — not more — may be added to half a pint of the oil. 1 

"By some one, then, of these means, modified according to the demands of 
each case, and carried out for a period varying from three to eight days, patients 
can be prepared, so to speak, for the administration of the oil, and many will be 
found to bear it now who previously would not have done so. 

" But when we come to give it I have found it useful to administer it with 
two distinct objects in view, and, for want of better terms, I must call these, 
1st, the alterative plan, and 2d, the fattening plan. The demands of each par- 
ticular case will, of course, guide us as to which plan we shall pursue. If the 
disease be in the early stage, and the loss of flesh little or none, but above all, 
if there be but little expectoration, the alterative plan will be employed. By 
alterative I mean here one or two drachms of the oil for an adult in the course 
of the day. If the effects of such doses be slow, the usual chronicity of the 
disease and its great obstinacy are never to be forgotten ; and, paradoxical as 
it may appear, a slow recovery is, in my experience, more to be desired than a 
more rapid one, the latter being very liable to relapse. That such doses as are 
now spoken of are capable of producing good effects, there can be no doubt, 
and they have the great advantage of not producing in any way untoward effects. 
That they will change the constitution from a state in which tubercles would be 
certain to be engendered, I myself cannot question. Even cases where I had 
reason to suppose tubercular deposit had occurred have got well ; but on such 
a point as this I would speak with great caution, believing, as I do, that it is not 
in the nature of things but that the diagnosis may have erred. 

"I have called this way of giving the oil the alterative plan, and it appears 
entitled to this, for it seems to act precisely as other medicines of this class do, 
such as mercury in small doses, the preparations of iodine, sarsaparilla, &c. ; 
and should the patient fatten on it, it is only as it were indirectly, and after a 
considerable interval. 

" On the second and more usual way of giving the oil, that is, from one to 
three ounces in the day, I have little to say, except that, like others, I have had 
opportunities of witnessing its good effects, even when the physical signs of 
tubercular disease were unequivocal. In these cases the signs of local disease 
all lessened, and, what was but too plain at one period, became subsequently 
much less so, whilst with this there was a corresponding improvement in all the 
constitutional symptoms. But I have seen no instance where the signs of local dis- 
ease — I mean after tubercles had softened — have entirely disappeared. Amongst 
my notes I find one instance where, after pneumothorax had occurred, life was 
prolonged for many weeks by the use of the oil. That the oil in large doses is 
an agent which often fattens the patient, and renews the health and strength, I 
presume few will now deny, and I must repeat that in my own hands it has 
shown itself far superior to any other single agent, including change of air. 

" Whilst using it in the large doses, however, there are one or two points 
which require attention. It has occurred to me to see some cases where the 
system appeared to get saturated with the oil, just as we know occurs with other 
medicines. The patients got out of sorts, the stomach did not retain, the oil as 
well as it had previously done, the tongue became somewhat furred, and the 
pulse of a fuller character than it had been ; in fact, a state of feverishness had 
been induced, and, as it appears to me, due directly to the effects of the oil. 
Under these circumstances, it is always necessary to omit the medicine for 
some days, and, when resuming it, to begin with smaller doses. The occurrence 

1 In cold weather even this quantity is too much. 
No. LXXIX.— July 1860. 15 



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Progress of the Medical Sciences. 



[July 



of the state of system alluded to may, however, be looked on favourably, as it 
indicates a power over the constitution which it were desirable to retain. 1 

" One other point whilst administering the oil in phthisical cases I would 
notice,, though aware it has been observed by all present ; I mean the fact that, 
in very many cases, and after a use of the medicine more or less prolonged, the 
disease comes to a stand as it were, or it may be the patient even begins to fall 
back. When the oil is first ordered the improvement is most marked, but a 
time comes when the good effects cease. Under these circumstances I was led, 
a considerable time back, to try some other remedies, which might take the 
place of the oil for a time, and was naturally directed to those which had been 
put forward as cures for phthisis, and which appeared to myself capable of at 
least affording relief. 

"This is not the place to enter into a discussion on a principle, as I may call 
it, in the treatment of chronic diseases, which seems to me worthy of much more 
attention than it has yet received ; I mean a change of remedies, having an ex- 
press object in view. In practical medicine, from the difficulties surrounding 
the subject, we are often compelled to change our remedies. This arises from 
the great uncertainty of their action. But every one hearing me will understand 
the difference between a medicine which has failed to do good at all, and one 
which has ceased to do good after having done some. There is certainty in the 
one case, but none in the other ; and though we have to change our remedies 
in both, it is yet done with a different intention in each. In the one we might 
resume what has formerly done good, in the other we would not think of it. 
Now, what occurs in phthisis is precisely a case in point. I have stated that 
whilst using the fish oil it was by no means uncommon to find it ceasing to 
benefit the patient. When this occurred, as it did again and again, I made trial 
of different remedies, of which hemlock, digitalis, and sarsaparilla may be men- 
tioned. I think I have seen some benefit arise from each of these ; it is not, 
however, of them I am about to speak, but of another medicine which has ap- 
peared to me more useful than any other single remedy I have tried, excepting, 
of course, the fish oil. The medicine I speak of is the uva ursi, and to it I beg 
to call the attention of the Society, as I consider that I have now had a suffi- 
cient experience of it. Most are probably aware that uva ursi had been recom- 
mended some sixty years ago as a cure for phthisis. It seems, however, to have 
fallen into disuse, at least for this disease, and besides it was recommended at a 
period when the diagnosis of chest affections did not approach the certainty 
which has since been attained. I would, therefore, again bring it forward, 
believing, as I do, that in some cases, to say the very least of it, it will be found 
a valuable adjunct to the other means for treating phthisis. In ordering it, I 
am in the habit of giving it in the form of powder, the dose ranging from five to 
fifteen grains, two or even three times a day. The form of powder has some 
objections ; to a few the idea of any medicine as powder is disagreeable ; but, on 
the other hand, it is much the most efficacious way of giving it, can be continued 
for months, and at a very trifling cost. 

" Given as indicated, it has appeared to me to act, in a minor degree, as the 
fish oil itself. Thus, it improves the strength, lessens the expectoration and 
cough, and it seems to act peculiarly well in relieving the dyspnoea, which, you 
are aware, is so often a leading feature of the complaint. The pulse, too, I have 
distinctly found, in some instances, to come down under its use. In a word, it 
improves the patient's general state, and, in a disease like phthisis, I take this 
to be a step of no little consequence. But it will not cure the disease, nor 
would I for a moment put it forward as being more than an auxiliary to other 
means. It does, however, I must repeat, improve symptoms, which, except the 
fish oil, I have found no other remedy effect. How it acts I do not profess to 
say, but it is more than probable its action is exercised on the bronchial mucous 
membrane, as we know it is in diseases of the urinary mucous membrane, that 
its use has been so long established, and retained to the present day. 

"When the fish oil seems to lose its effects, I have been in the habit of substi- 

1 In direct connection with this part of the subject, I may refer to a valuable 
paper brought before this Society a few years back by Dr. Benson. 



I860.] Medical Pathology and Therapeutics. 



227 



tilting the uva nrsi in its place ; and, in this way, I believe more benefit is attained 
than in any other way, and after some time again the oil may be resumed as at 
first, and with good effect. In several instances I have given the two medicines 
conjointly, but at different times of the day." * * * # * 

" Thus' the oil has been ordered after breakfast, and the uva ursi towards 
evening. It has appeared to me in such cases that the improvement of the 
patients was unusually rapid, but they are as yet too few to enable me to form 
a definite opinion on the point. It is not by any means improbable, however, 
that the action of the uva ursi on the mucous membrane, especially of the 
stomach, may be such as to render the oil a more efficient agent than it even is 
at present. Should this opinion — and I see no reason to doubt it — turn out to be 
correct, an important step would be gained, for less oil would then be required, 
and our power over the fearful disease under consideration would be increased. 

" Before concluding, the Society will allow me to put into a series of proposi- 
tions the points to which their attention has been already drawn, and on which 
I should be glad to have their opinion. 

" 1. That in some cases of phthisis, treatment is essential preparatory to the 
use of the codfish oil. 

"2. That this result is probably best attained by the use of some of the pre- 
parations of potash. 

" 3. That the fish oil may be given with two separate objects in view, 1st. as 
an alterative, and 2d, as a direct restorer of the flesh and strength ; the amount 
of the dose being the cause of this difference. 

u 4. That the oil, in some instances, seems to saturate the system, under 
which circumstances, its use ought to be suspended. 

" 5. That in many cases, after a certain use of the oil, its good effects cease. 

" 6. That it is then advisable to substitute some other means. 

" 7. That amongst these the uva ursi is well worthy of a trial. 

"8. That in some instances the use of the oil and uva ursi conjointly would 
appear to lead to the best results." — Dublin Medical Press, April 11, 1860. 

7. Treatment of Phthisis by the Hypophosphites of Soda and of Lime. — Dn 
Richard Qttaix was induced by the representations of Dr. J. F. Churchill, rela- 
tive to the value of the hypophosphites of soda and of lime in the treatment of 
phthisis, to administer these agents to twenty-two patients in the Brompton 
Hospital for Consumption. Two of these were in the first, two in the second, 
and ten in the third stage of phthisis. The dose given, was at first ten grains 
three times a day, and increased in some cases, to a drachm. One case was 
under treatment six months, one four months, six three months, nine two 
months, and five one month. " During this lengthened course of treatment," 
says Dr. Q., "I looked anxiously, but in vain, for those marked physiological 
effects described by Dr. Churchill. There were no evidences of the 'improved 
powers of innervation;' 'the hair and nails did not grow more rapidly;' there 
was no ' appearance of plethora or of fulness ;' the patients did not describe ' an 
unaccustomed sensation of feeling better and stronger after a few doses of the 
remedy.' Nay, I would say that there was nothing more felt by the patient nor 
noticeable by the physician than if so many grains of carbonate of soda or pre- 
pared chalk had been taken." 

Dr. Q. gives the following summary of the results of the treatment : " Of 22 
individuals labouring under phthisis, submitted to the hypophosphite treatment, 
sixteen derived no benefit whatever ; in three the benefit was so slight and tem- 
porary as scarcely to deserve notice ; in two the improvement, though marked, 
was temporary ; and in one case the result has been satisfactory and permanent. 
Small as the therapeutical powers of the hypophosphites are shown to be by 
these facts, are we justified in assigning to them even thus much ? I think not. 
For we cannot forget that our cases are hospital cases; that, oppressed by sick- 
ness, care, and anxiety, they come from close, unhealthy localities ; that they 
were more or less destitute of good food and good air. When they enter the 
hospital, they begin to feel the influence of hope ; they live in warm, airy, and 
well-ventilated wards, find agreeable occupations, and have plenty of good food, 
Under such circumstances, the patients frequently improve in health, without 



228 



Progress or the Medical Sciences. 



[July 



the application of any medicinal agents. It would, therefore, be as fair to attri- 
bute the slight or temporary improvement which took place in some of these 
cases to hygienic as to the therapeutical agencies. Nay, further : this opinion 
is confirmed by the fact that two of the three cases which did best in the hos- 
pital ceased to do well when they left it. 

"Desirous of otherwise testing the value of these substances, I thought it 
would be well to compare the results of my ordinary hospital practice with that 
of the hypophosphite treatment. With this view, I requested my friend and late 
clinical assistant, Dr. Hill (to whom I am indebted for much assistance in this 
inquiry, and for the notes of the preceding cases), to make abstracts of any 22 
successive cases in the hospital books. He did so, and having ascertained the 
results of the treatment in these cases, I find that he has given me notes of 11 
males and 11 females, of whom 3 were in the first stage of the disease, 5 were 
in the second, and 14 in the third. It will be remembered that 12 were in the 
first and second stage, and 10 in the third. Thus in the former cases, the ad- 
vantage was in favour of the hypophosphite cases, so far as the stages of the 
disease were concerned ; nevertheless we find that of the cases submitted to 
other treatment, 16 were more or less materially or permanently benefited, 
whilst in 6 only did the disease progress unfavourably. Exactly the converse 
was the case when the hypophosphites were given. Thus there were 16 of 22 
cases unrelieved. This comparative evidence is further strengthened by bearing 
in mind that 6 of the cases in the former series, which were unrelieved by hypo- 
phosphite treatment, did well subsequently under other treatment. 

" A review of the preceding facts has led me to form a most unfavourable 
opinion of the value of hypophosphites in the treatment of phthisis. I believe 
them to be comparatively, if not absolutely, useless. I have been induced to 
take some little pains in investigating the subject, because of the unhesitating 
confidence with which their value is asserted and their use recommended in 
certain quarters, and I have also seen in the cases of some patients who have 
visited Paris how much time has been thrown away by substituting the use of 
these salts for remedies of undoubted efficacy in controlling the progress of 
phthisis." — Lancet, March 17th, 1860. 

8. Rheumatism treated by the Hypodermic Injection of Atropia. — Dr. 
Cowdell, of the Dorset County Hospital, reports [Med. Times and Gaz., 
March 17, 1860) five cases as evidences of the great practical value of the hypo- 
dermic injection of atropia in sciatica, lumbago, and, in fact, all external aches 
and pains ! Dr. "Wood's morphia injection, Dr. 0. says, has been practised on 
several patients without the results now obtained from the use of atropia. The 
morphia procured sleep in from three to ten minutes, but when the narcotic 
effect had passed off, the pain returned as bad as before. The atropia causes 
slight drowsiness, dryness of the throat, and dilatation of the pupil ; the only 
symptom of moment being the disappearance of the pain. The sulphate of 
atropia being more soluble than the alkaloid itself, is preferred ; the strength of 
the solution is gr. ij to ^j of water. The instrument employed is an ordinary 
naevus injecting syringe, consisting of a graduated tube with screw piston, and 
a hollow needle which screws on to the tube. The needle is thrust under the 
skin as near the seat of the pain as possible, and from ten to thirty minims of 
the solution gradually injected. 

We quote one of Dr. C.'s cases — 

Case. — S. E., aged 20, a domestic servant, admitted September 29, 1859, and 
stated as follows : " Had an attack of acute rheumatism five months since, was 
delirious at intervals during three weeks, and, when recovering from the rheu- 
matism, sixteen weeks ago, had an acute pain in the hip, which did not yield to 
the leeches or blister which were repeatedly applied." On admission she was 
extremely anaemic, and experienced acute pain in the region of the sciatic nerve, 
increased by pressure. There was no hip affection ; contour of hip normal ; 
muscles very flabby ; hamstrings contracted ; knee bent ; and the foot drawn 
up. She had, during the whole time, been unable to walk without crutches. 
Ordered meat diet. 01. morrhuaB and a draught containing iodide of potassium. 



I860.] 



Medical Pathology and Therapeutics. 



229 



30th. Passed last night as usual, without sleep, and in agonies of pain. Injice 
sol. atropise sulph. nixxx in par. dolent. 

October 1. Slept well all night ; felt immediate relief after the injection ; says 
she has not had so good a night for sixteen weeks. 

4th. Hip is sore, but no pain unless pressed. Eepet. inject, hora somni. 

hth. The pain is entirely gone, not even the soreness remaining. Omit. mist. 
R. — Ferri. am. cit. gr. iv, ex aq. ter die. 

She was treated for anaemia from this date to November 10, when the report 
runs thus : — 

"November 10. Patient has had no pain in the hip since the last injection on 
October 4. Two injections only were employed, at an interval of three day?, 
the first of which gave immediate relief, the second removed pain and soreness 
altogether. Can walk with ease ; no pain on pressure over the nerve, and she 
gains flesh rapidly. Discharged well." 

9. Successful Treatment of Eooping-Cough, by increasing Doses of Sulphate 
of Zinc and Extract of Belladonna. — Dr. Fuller read a paper on this subject 
before the Harveian Society of London (April 19, 1860). He commenced by 
calling attention to the commonly-received opinion, as stated in most books on 
the subject, that "hooping-cough must run a certain course." He combatted 
this opinion by reference to the results of his own experience, and then pro- 
ceeded to point out the causes which had led to its general adoption. Among 
these he mentioned the inefficiency of the treatment ordinarily employed, and 
the neglect of all measures likely to subdue the tendency to spasm on which the 
continuance of the whoop depends. Dr. Fuller regarded the complaint as con- 
sisting essentially of bronchitic irritation, usually not very severe, accompanied 
by reflex spasm of the air-passages, and expressed his opinion that in most cases 
the spasmodic symptoms are those which demand our most serious attention. 
Not only is the spasm a most painful symptom, but it is one which may give 
rise to life-long mischief. His object, therefore, had always been to subdue the 
spasm as speedily as possible, and the practice which, until the last twelve 
months, he had found most successful for the purpose, was the administration 
of sulphate of zinc in rapidly increasing doses. Dr. Fuller then referred to the 
discovery he had made as to the tolerance of belladonna by children, which is 
recorded in a paper published in the last volume of the Med^co-Ohirurgical 
Transactions, and he briefly stated the facts which are there detailed in extenso, 
as to the amount of belladonna which may be given with safety, and the condi- 
tions which should be observed in its administration. The conditions he speci- 
fied were, first, that the remedy should be given at least four times daily, and 
should be administered at first in small doses, which may be increased day by 
day or on alternate days, by a corresponding amount. He pointed out that mere 
dilatation of the pupil need not be regarded as a bar to its administration, and 
stated that if the precautions just referred to are observed, the daily dose of the 
extract of belladonna may be safely increased up to a scruple or half a drachm 
Without the production of any unpleasant symptoms. He then proceeded to 
state that he had brought these facts to bear on the treatment of hooping-cough, 
and from the conjoint use of sulphate of zinc and extract of belladonna, in rapidly 
increasing doses, had obtained results exceeding his most sanguine expectations. 
Barely had he found the whoop to last above twenty-one days, and in some 
instances it had subsided in ten days. The mode in which Dr. Fuller proceeds 
is to give the zinc and belladonna as soon as the whoop declares itself. If the 
attack is accompanied by much febrile excitement, and bronchitic irritation, he 
prescribes a cough-drop containing a drachm of antimonial wine and a drachm 
of ipecacuanha wine to two ounces of water, and, if necessary, applies a blister 
to the chest. Of the cough-drop, a larger or smaller amount is given according 
to circumstances. In all cases, however, the zinc and belladonna are persever- 
ingly administered. To children under three years of age he usually begins by 
giving one-sixth of a grain of extract of belladonna, and half a grain of sulphate 
of zinc four times daily; and to children above that age one-quarter of a grain 
of extract of belladonna and a grain of sulphate, of zinc. These remedies are 
given in solution in water, and the dose of each substance is increased by a cor- 



230 



Progress or the Medical Sciences. 



[July 



responding dose daily, or on alternate days ; so that the child who began by 
taking one-quarter of a grain of the extract and one grain of zinc at a dose, 
would be taking one grain of the extract and four grains of the zinc at a dose, 
either on the fourth, the sixth, or the eighth day, according to the rapidity with 
which the dose is increased. Dr. Fuller concluded by citing cases illustrative 
of the value of this treatment ; assured the members of its safety, and urged its 
general adoption. 

10. Nitrate of Silver in Diphtheria. By Dr. Hauner. — Seeing the difference 
of opinion which prevails as to the efficacy of this remedy, it is of importance 
to exactly determine what cases are suited for its application, how far it operates 
alone or in consequence of its being combined with other remedies, and what is 
the best manner of employing it. It is only by the exact observations of nume- 
rous well-marked cases that these points are to be elucidated. 

During fourteen months of 1857-8, scarlatina, pertussis, and measles prevailed 
greatly in Munich, where the author practises, and a very large number of child- 
ren became the subjects of one of these diseases, very many of two of them, and 
some of all three. The scarlatina, as a general rule, was very mild, few children 
dying ; the pertussis gave rise, owing to the tediousness of its catarrhal stage, 
to emaciation, but during its convulsive period it proved very amenable to reme- 
dies ; while the course which the measles pursued was by no means so simple. 
There was no unusual mortality from bronchial or pneumonic inflammation ; but 
the eruption in many cases, in its colour and its course, assumed the form of what 
is by some termed typhoid or putrid measles. The fever was very persistent, the 
paroxysms of cough were excessively violent, and the inflammation of the mucous 
membrane of the fauces, larynx, and bronchi was often intense. The patients 
were very slow in recovering, long remaining feeble, especially such of them as 
had already been attacked by scarlatina or pertussis. During the prevalence of 
these exanthemata, a diphtheritic condition of the mouth and throat was occa- 
sionally met with ; but this readily yielded to aqua oxymuriatica, chlorate of 
potash, and slight cauterizations ; and it was not until after the cessation of the 
exanthematous diseases that the diphtheritis broke out as an epidemic. The 
author's views on this disease already formed were amply confirmed by the ob- 
servations of the present epidemic ; and he considers that the following positions 
may be laid down with complete certainty : 1. Diphtheritis only attacks children 
who are debilitated from former disease, that usually being of an exanthematous 
character. 2. It is contagious, and may be conveyed from diseased to hitherto 
healthy children. 3. Death may be produced through intoxication or pyaemia, 
through exhaustion, or through the local extension of the disease to the larynx, 
bronchi, and lungs. 4. The treatment should consist in the prompt arrest of 
the progress of the disease towards organs dangerous to be affected, and the 
administration of internal roborants. 5. The antiphlogistic treatment is directly 
injurious. 

In the present epidemic 82 cases came under the author's notice, 46 suffering 
from diphtheritis faucium et oris, 8 from angina diphth. gangrenosa, 6 from 
ozaena diphtheritica, 10 from laryngitis diphth., 5 from diphth. vaginae, and 7 
from diphth. cutanea. Exact inquiries ascertained that of these 82 patients 39 
had suffered from measles, 15 from scarlatina, 19 from pertussis, and 7 from all 
three of these within the space of fifteen months. In 7 instances the children 
had been healthy until brought into immediate contact with those suffering from 
diphtheritis. With respect to age, only 8 of the children were less than one 
year old, the ages of from two to eight being those of the bulk of the cases. 
The sexes were nearly equal. Although in some of these cases the children were 
surrounded by the best sanitary conditions, the majority, whether as regarded 
diet, residence, and care, were not so provided for. Of the 82 children, 6 died — 
2 from laryngitis and diphtheritic bronchitis, 1 from cutaneous diphtheritis (a 
post-mortem, which might have discovered internal lesions, being prohibited), 1 
from pyaemia coming on during gangrene of the cheek, and 2 from atrophy after 
the diphtheritic process had ceased. 

While the primary cause of the origin of a diphtheritis must be looked for in 
the preceding occurrence of another disease, it is not to be doubted that the 



I860.] Medical Pathology and Therapeutic 



231 



careful treatment of a child so affected, with good food and nursing, healthy 
dwelling-place, etc., may prevent the outbreak of the diphtheritis, and its spread- 
ing by contagion can be entirely hindered. Sporadic cases, which often come 
under observation, are not of the same importance as during the prevalence of 
an epidemic. 

In all the cases during this epidemic the nitrate of silver was employed. The 
diphtheritic deposits of the mouth and throat were immediately well pencilled, 
and especially was the nitrate applied to and beyond the cutaneous deposits. 
Instead of the solid nitrate, a solution of from twenty to thirty grains to the 
ounce was also employed sometimes ; and the author believes that the having 
prompt recourse to this local application, accompanying it by internal strength- 
ening means, prevented the propagation of the pseudo-membranes to more im- 
portant organs. Of the internal means, good meat-broth (Liebig's extract of 
flesh), coffee, beer, wine, etc., together with quinine and the chlorate of potash, 
were those chiefly had recourse to. Sometimes, at the commencement of the 
affection, an emetic of ipecacuanha and oxymel of squill was given with evident 
advantage. Baths were also employed, and the greatest cleanliness observed in 
the administration of food, etc. ; while the fauces were frequently examined, all 
new deposits being removed and the caustic reapplied. In no instance did a 
case of the author's so treated pass into diphtheritic croup. The ten cases of 
diphtheritic laryngitis were treated by application of the nitrate to the larynx, 
and all but two recovered. In six of the cases which recovered the most unfa- 
vourable prognosis had been delivered. In three of the cases the cauterization 
was repeated five times in the twenty-four hours ; in two, four times ; and in one, 
only twice ; in four cases it was performed by Green's mode of applying the 
pencil, and in two by blowing in the powdered nitrate. Not only did the nitrate 
excite powerful cough and vomiting, whereby strips of false membranes were 
expelled, but after a few hours the breathing became easier and deeper, and the 
circulation more equalized. Sanguine as are the author's expectations of the 
benefits to be derived from the nitrate in diphtheritic croup, he yet believes that 
there are cases in which its most skilful application will fail to be of service ; 
but still he maintains that there is no other remedy which produces so rapid, 
certain, and unmistakable effects. Even after laryngotomy in this disease, the 
nitrate is still almost indispensable for the completion of the cure. After its 
employment, he finds it best to keep the parts surrounded by a moist heat, to 
which end compresses wrung out in water are kept around the neck, or cata- 
plasms are applied in vaginal or cutaneous diphtheritis. The loss of substance 
under such, applications is more quickly supplied, granulation and cicatrization 
taking place much more rapidly. Above all things, the author cautions practi- 
tioners against adopting active antiphlogistic treatment in epidemic diphtheritis, 
affecting children, as it generally does, already enfeebled by prior disease. — Med. 
Times and Gaz., March 10, from Froriep's Notizen, 1859, Bd. II., No. 21. 

11. On the Comparative Results of the Treatment of Croup by Tracheotomy 
and by Medication, during the years 1854—58. — Dr. Barthez, in a letter ad- 
dressed to Dr. Rilliet, inquires into the causes which may account for the vary- 
ing results obtained by the medical and surgical treatment of croup. He seeks 
to determine the conditions which in each case influenced these results, so as to 
arrive at a safe basis upon which to decide upon the value of tracheotomy. 
During the first year after the Hopital St. Eugenie was opened, 13 cases were 
submitted to tracheotomy. The first died during the operation, and successively 
eleven others died after operation ; it was not till the thirteenth that a cure was 
obtained. On the other hand, four patients who were not operated upon reco- 
vered. The fatality of the operative proceedings now induced Dr. Barthez to 
be more sparing of the knife ; but still the ensuing year brought a great fatality 
— of 18 patients only four recovered. Two had been tracheotomized. But at 
this period French physicians began to distinguish between simple and infectious 
croup or diphtheria, and Dr. Barthez arrived at the conclusion that the disease 
(croup and diphtheria being employed synonymously) was the result of an in- 
toxication giving rise to two forms of morbid action — the one local, pseudo- 
membranous ; the other general or infectious. The author now considered the 



232 



Progress or the Medical Sciences, [July 



operation inadmissible in the form that was primarily malignant, on account of 
its rapid progress ; while he held that it should be done where the disease was 
slow in its progress, and, although severe, only induced asphyxia slowly. The 
asphyxia ought to be combated by operation, whatever the previous health of 
the child. At this time he laid down the following rules : 1. To try internal 
remedies, which had been most successful ; 2. To perform tracheotomy at an 
advanced period, when the former method had evidently failed ; 3. To operate 
also, however unfavourable the age and prior health of the patient, if there were 
evidence of impending asphyxia. 

This method was not followed by great success during 1856, for among 18 
cases there were only four recoveries, of which three had been tracheotomized. 
During 1857, however, the author's views appeared justified by his results, for 
among 33 cases (croups) there were nine cures, seven of which were without 
operation. Two of these were fortunate enough to have been brought out for 
operation, but to have been sent back for a further trial of internal treatment. 
Of 23 who were operated upon but two recovered : however, the author expresses 
himself well satisfied with this result (je le trouvai tres beau), for the two pa- 
tients were snatched from certain death by the operation. The general results 
obtained during the course of 1858 were as follows : Total number operated upon, 
124, with a mortality of 106, or 1 recovery in 6.9 ; total number not operated 
upon, 62, with a mortality of 26, or 1 recovery in 2.4. With regard to the 
character of the disease during this year, the author remarks that it presented 
successively all the forms of diphtheria ; the recoveries accumulated at certain 
periods, while at others the number of deaths was terrible. From the 1st of 
January to the 3d of June the non-infectious form, accompanied by slow and 
feeble intoxication, prevailed. The false membranes descended to the small 
bronchi ; tracheotomy, which was almost invariably performed, scarcely yielded 
one recovery in 6 or 7 cases ; and the recoveries nearly all took place in Febru- 
ary. During June the epidemic almost ceased, to recover its virulence towards 
the end of July. During August it was so severe that of 12 children none reco- 
vered by the operation. In September and October there were four recoveries 
among 14 patients ; then, after a respite of a few days, the epidemic appears 
more severe than ever, and with great efforts but one cure is achieved among 14 
patients. 

The author concludes from the preceding facts that it is not the treatment 
which determines the results, but that we must seek for the causes of the varia- 
tions observed regarding them in the varying forms of the epidemic. 

Although Dr. Barthez regards the two varieties of diphtheria as "the ex- 
pression of the same affection," which often renders it " difficult to establish a 
distinction at the bedside," he considers it necessary to make the distinction, 
because the results of the treatment are so different, according as the diphtheria 
is local or general. In a subsequent part of the paper, though admitting the 
doubtfulness of the statistics, he states that of 55 patients in whom the disease 
put on the general type, only 7 recovered, or about 1 in 8 ; while of 64 patients 
where the disease was of the local character, 27 recovered, or 1 in 2.3. 

The following are the characters which Dr. Barthez regards as distinctive of 
the two forms of the disease : — 

1. When the false membranes extend in a continuous layer over the palate, 
uvula, tonsils, so as to spread into the respiratory passages, he considers gene- 
ralization of the disease certain ; and still more so if the nasal fossae are attacked. 
On the other hand, the absence of coryza, the limitation of the false membranes — 
i. e., their exclusive formation in the larynx, or their slight extension to the 
tonsils only, are the features which appear to indicate the absence of general in- 
toxication. 

2. The gray, grayish-black colour, the gangTenous appearance of the false 
membranes visible on direct inspection, the discharge of a blackish liquid and 
ichorous blood on the slightest touch of the throat, are certain signs of intoxica- 
tion ; while the gray-yellow, and above all the white tint, of the false membrane 
indicates local disease. 

Diphtheritic intoxication is further characterized by marked tumefaction of 
the cervical ganglia of a painful character, especially if accompanied by swelling 



I860.] Medical Pathology and Therapeutics. 



233 



of the adjoining cellular tissue; by the production of false membranes on the 
skin when deprived of its epidermis, and on wounds ; by gangrene of the mucous 
membranes of the skin or of wounds ; by abundant albuminuria, which is inde- 
pendent of all other causes which may produce it (upon this symptom the author 
was "imperfectly informed" up to the end of 1858); by the leaden, and not 
purple, hue ; the smallness and feebleness of the pulse ; the exhaustion apart 
from the asphyxia, or out of proportion to the apparent asphyxia. Finally, 
diphtheritic intoxication is characterized by consecutive paralysis, either limited 
to the pharynx or general. — Brit, and For. Med.-Chir. Rev., April, 1860, from 
Gazette Heldom., Dec. 2, 1859. 

12. Bloodletting in Disease. — Dr. Maekham read a paper on this subject be- 
fore the Western Medical and Surgical Society (March 2d, 1860). The author, 
apologizing for the triteness of the subject, drew a complete distinction between 
the effects of local detraction of blood from an inflamed part, and the effects of 
venesection upon it. Local abstraction of blood, as by leeches applied to an 
inflamed joint, generally reduces the chief characteristics of the inflammation, 
the pain, the heat, the redness, and swelling ; but venesection has no such in- 
fluence over those inflamed parts, nor any influence at all except such as is 
always manifested when large quantities of blood are taken. Now, if these facts 
be true of external inflammation, he argues they must, by strict analogy, be true 
of internal inflammations, and therefore local abstraction of blood is useful in 
all those cases of internal inflammation in which there is a distinct vascular 
connection between the skin and the inflamed part beneath it, as, for instance, 
in pleurisy and peritonitis. He contends, however, from what we see of its 
action in external inflammation it has no beneficial influence over internal in- 
flammations. How comes it, then, that the wisest of our profession have in all 
ages deemed the remedy so useful a one in all such internal inflammations ? Are 
we to believe they have all been mistaken ? The author answers these questions 
in a decided negative, and thus solves the difficulty. He calls attention to the 
fact that the chief (and only) battle-field in which the bloodletting controversy 
has been ever fought is pneumonia. This, then, is the disease in which the 
benefits of bleeding must have been most beneficially exemplified, and the prac- 
tice may have been right, though the theory may have been wrong. Men 
thought the bleeding had a directly beneficial influence over the progress of the 
local inflammation in the lung, but it was not so ; it simply relieved the pul- 
monary and the cardiac congestion, which necessarily arises in a greater or less 
degree, as a complication of pneumonia. This is the only relief it gives ; it frees 
the partiaHy-arrested pulmonary and cardiac circulation, and gives intense relief. 
Its benefits, therefore, are great and immediate, and its dangers all lie in the 
future. The greater the extent of the inflammation, the greater the asphyxiating 
congestion, and the more urgent the necessity for venesection ; but, unfortu- 
nately also, the greater is the danger of the practice. Eecollect, the lungs are 
the chief blood-making organs of the body, and this all-important function is 
arrested in proportion to the extent of the inflammation. The loss of blood is, 
therefore, under such circumstances, an irreparable loss. He ridicules the fear 
which many have of large losses of blood, and asserts that the body will lose 
such with impunity, provided the lungs remain unaffected by disease, i. <?., so 
long as the lungs can make fresh blood from the food and wear and tear of the 
tissues. As a striking proof of this fact, he instanced the large hemorrhages 
borne by women in childbed, and by fever patients with abdominal symptoms. 
As a corollary of his views of the indirect uses of venesection, it follows that it 
is an excellent remedy in all those diseases, whatever their nature, which occa- 
sion a congestive condition of heart and lungs, as in pneumonia ; and he in- 
stanced diseases of the heart, peritonitis, and injuries of the head, as cases in 
which this condition of the pulmonary circulation obtains, and which require 
venesection. He concluded by stating, that if his views of the effects of vene- 
section are accepted, viz., that it has no beneficial influence over the inflamma- 
tion per se, but only in those cases in which pulmonary and cardiac congestion 
arise, it must follow that a very different signification from that generally adopted 
must be attached to the remedy. It also follows, he thinks, that the remedy is 



234 Progress of the Medical Sciences. [July 

now-a-days much less frequently resorted to than sane therapeutics require. 
The change-of-type-of-disease theory in no way affects the position he here 
assumes as to the uses of bleeding. Whether that theory be true or false, the 
action of bleeding in disease, be it good or be it bad, must be physiologically 
the same. That theory can only affect the necessity or otherwise of our resort- 
ing to the remedy in given cases : it cannot alter its mode of action. He, 
therefore, thinks the discussion unnecessary. — Med. Times and Gaz., March 31, 
1860. 

13. Clinical Experience in Pneumonia. — Dr. Gairdner states [Edinburgh 
Med. Journal, March, 1860) that, while acting as pathologist to the Edinburgh 
Royal Infirmary from 1848 to 1853, he had become convinced that the tendency 
to death of many inflammatory diseases, and, in particular, of inflammation of 
the lungs and pleura, when uncomplicated, was very much overrated. This he 
inferred from the rare occurrence of deaths due to pneumonia and pleurisy (and 
also to pericarditis, peritonitis, and acute meningitis), apart from those organic 
diseases or surgical accidents, which might be said naturally to terminate in one 
or other of these acute affections. He also inferred, from his experience as 
pathologist, that this tendency of inflammations to a favourable result was on 
the increase ; or rather, that, in proportion as we were getting rid of the severe 
forms of epidemic disease (fever, dysentery, scurvy, influenza), which had de- 
teriorated the health of the population previously to 1848, we were also getting rid 
of the more severe and unmanageable types of acute inflammation ; especially the 
inflammations of the serous membranes of the chest and abdomen, which he had 
seen in fearful activity during a few months of the year 1847, and pneumonia, 
which, within his own experience as a student, had been a much more fatal dis- 
ease in hospital practice than it ever became after 1848. 

Into the causes of this favourable change, he does not propose at present 
minutely to inquire, although the inquiry is one of great importance. He be- 
lieves, however, that the acute inflammations are quite as much, or very nearly 
as much, within the domain of the sanitary reformer as the more obviously 
epidemic fevers ; and further, that some even of the chronic organic diseases 
have already yielded, and may be expected still further to yield, to the improved 
habits, the better clothing, the greater abundance of food, and the diminished 
destitution of the population generally. Looking back over thirteen years of 
almost continuous hospital experience, he feels assured that chronic affections of 
the kidney and liver, and perhaps also of the heart, have diminished in frequency, 
as causes of death, to a most material extent. 

In his paper, Dr. Gairdner proposes to illustrate the actual state of the case 
as regards pneumonia, or rather pleuro-pneumonia, by submitting a brief report 
of the mortality in his wards, in so far as it bears on this disease, during five 
complete years ending in December, 1859. There is only one way of doing this 
so as not to mislead ; viz., to give an account of all the deaths, whether directly 
from pneumonia or not, in which decided pneumonia formed part of the disease 
existing at the time of death. He enters a caution against using the data as 
statistics of death and cure, to be set against other statistics of death and cure, 
possibly founded on a different estimate of pneumonia ; and against arguing 
from these data as confirmatory of any special principle of treatment in pneu- 
monia, inasmuch as his treatment has not been at any time founded on special 
or peculiar principles, but simply on the watchful adaptation of means to ends 
in the individual case. 

For several years before 1855, while Dr. Gairdner was occupied as assistant- 
physician and junior acting physician to the Infirmary, the cases under his per- 
sonal care were, to a disproportionate extent, instances of chronic disease, and 
were limited to the male sex. Since that period, owing to arrangements among 
the ordinary physicians with regard to clinical teaching, he has never had under 
his care fewer than fifty beds fairly divided between male and female patients ; 
all the male, and by much the greater proportion of female beds having been 
devoted to ordinary miscellaneous cases, most of them severe and urgent ; and 
the succession of these having been, as a rule, rapid and varied. 

The following is his entire personal experience of fatal acute inflammation of 



I860.] Medical Pathology and Therapeutics. 235 



the lungs, whether simple or complicated, during the five years from 1855 to the 
end of 1859. 

In 1855, the only case of this kind that occurred to him was one of double 
pleurisy, with pysemic abscesses in the lung, from a fish-bone imbedded in the 
cellular tissue behind the oesophagus. In 1856, there were three fatal cases of 
pulmonary inflammation ; all, however, evidently secondary to grave disorders, 
sufficient of themselves to compromise life, and of older standing than the pneu- 
monic affection. One of these patients, aged 40, was said to have been an epi- 
leptic ; he had fallen (it was said) during a fit, and had injured his head ; he lived 
for eight days with all the signs of compression of the brain, and was afterwards 
found (as was suspected before death) to have fractured the skull in the lateral 
regions and at the base. The pneumonia in this case presented hardly any 
symptoms. In another case, aged 43, there was severe maniacal delirium tremens, 
which was afterwards discovered to be complicated with fracture of the first 
rib, diffused abscess around the seat of the fracture, suppuration of the shoulder- 
joint, and pyaemia. This case is noticed in the Edinburgh Medical Journal for 
August 1856, p. 129. The third case was one of broncho-pneumonia supervening 
on Bright's disease of the kidney. 

In 1857, there were two fatal cases of pneumonia, both secondary to chronic 
organic disease. The first was only two days in hospital. He was an intem- 
perate man, the subject of Bright's disease, and, as was afterwards found, of 
fatty liver in a high degree. He was admitted on January 1st, far gone in double 
pneumonia, and with intense albuminuria and renal desquamation. He died on 
the 3d. The other case was that of a man, aged 39, subject to aggravated 
chronic bronchitis and emphysema for nearly a year before his death, which oc- 
curred from the complication of these disorders with a rather chronic condensa- 
tion of the lower lobe of the left lung. 

In 1858, there were two cases of pulmonary inflammation under treatment, and 
ending in death. One, in a woman, aged 39, was complicated with Bright's dis- 
ease of the kidney, in an advanced stage. The other, a man, aged 30, was a 
case of emphysema and bronchitis of old standing, on which pneumonia had 
supervened about a week before admission. A child, also, of 15 months, ap- 
parently of feeble organization from birth, was brought to Dr. Gairdner evidently 
moribund. It died two hours after admission, and considerable inflammation of 
the lungs was found. 

In 1859, Dr. Gairdner witnessed, within the space of a little more than a week, 
two more fatal cases of pneumonia, one of which only was complicated. Neither of 
these cases was under treatment more than forty-eight hours. The complicated 
case was one of severe and long-standing emphysema and bronchitis, with car- 
diac dilatation to a moderate degree, admitted in extremis on the 4th of June, 
and dying on the 5th of June. The other case was that of a man of exces- 
sively intemperate habits, admitted with absolutely complete hepatization of the 
upper lobe of the right lung, which was so much enlarged by inflammatory 
effusion as to cross the middle line of the sternum, and was already becoming 
disintegrated by suppuration, with the characteristic prune-juice expectoration 
in very large quantity. The patient had been ill only about a week, but was 
exceedingly exhausted on admission. The treatment was almost exclusively by 
stimulants ; but he died on the second day after entering the hospital, and the 
ninth of the disease. There was no organic complication. 

The preceding details show, that out of ten or eleven cases of inflammatory 
affections of the lungs, being absolutely the whole number that can be disco- 
vered after the most diligent search, in which acute pneumonia, or anything like 
acute pneumonia, occurred among all the cases terminating in death under Dr. 
Gairdner's care from 1855 to 1859, only one can fairly be said to be a death from 
idiopathic or uncomplicated pneumonia. In this one case the disease occurred 
in a man of excessively intemperate habits, and had gained ground so far before 
admission that the whole upper lobe of the right lung might be said to be in a 
state of destructive suppuration. Dr. Gairdner believes also, that in no one of 
these cases had anything approaching a rigidly antiphlogistic treatment been 
pursued, either before or after admission. Many of them, indeed, had been en- 
tirely neglected ; but in such as had been seen by medical men before admission, 



236 Progress or the Medical Sciences. [July- 

it had apparently never occurred to the medical man to use such treatment ; 
and, in particular, not one of all these fatal cases was bled. The treatment in 
the hospital, so far as treatment was possible, consisted of diffusible stimulants 
and cough mixtures, with such food as could be taken, mild diuretics, and, in 
one or two, the extremely cautious use of antimony. 

During the same period (1855-1859), Dr. Gairdner treated, on an average, 
from twelve to twenty cases of inflammatory disease of the lungs annually : or, 
in the aggregate, from 60 to 100 cases, including under the larger number a 
rather vague estimate of all kinds and varieties of disease in which acute or 
serious symptoms went along with the evidences of pulmonary condensation ; 
and under the smaller, a rather restricted calculation of those cases which he 
regarded at the time as being genuine pneumonia. He has long been of opin- 
ion that not all cases attended with pulmonary condensation, and marked by 
acute symptoms, are pneumonia in the proper sense of the term ; and he there- 
fore leaves it to the reader to take either the larger or the smaller number, accord- 
ing to his own idea of what should be called pneumonia. 

Dr. Gairdner does not advocate any one special system of treatment in pneu- 
monia. He holds that what is to be treated is not so much the pneumonia, as the 
individual patient. Nevertheless, he thinks it right to state shortly the rules 
by which he has been guided in the administration of remedies. Among single 
drugs, antimony has been first on his list : the greater nnmber of cases (not ex- 
cluding some of those which appeared most debilitated) , which were attended 
by marked fever and oppression, had it in one shape or another ; commonly in 
the ordinary form of tartar emetic, in doses varying from one-twentieth of a 
grain to one grain every hour or two. He has given the antimony always alone, 
i. e., with nothing to mask its physiological effects ; and has always simply 
withdrawn it, or diminished the dose, so soon as any form of unfavourable effect, 
such as vomiting, purging, or depression of the system, was continuously mani- 
fested. This he believes to be better practice, on the whole, than the current 
method of giving the antimony with opium. He has always withdrawn the an- 
timony the instant the fever appeared to be decidedly checked, and the patient 
in the way of convalescence ; having rarely found any relapse to follow from 
this practice, which has the great advantage of allowing the diet of the patient 
to be carefully adjusted to his capabilities of digestion in convalescence, with- 
out the chance of disturbance by a superfluous medicine. Very many mild cases, 
and some severe cases coming on late in the disease, have been treated by little 
more than common cough mixtures. Opium has sometimes been given, but 
chiefly as a palliative ; calomel with opium (indeed mercury in any form) has 
been very little employed ; having been given only in obstinately continuing 
condensations, and then only as an experiment, with great caution, and with 
little positive result. Blistering has been reserved, for the most part, for severe 
cases and obstinate condensations threatening to become chronic ; poultices, 
warm fomentations, turpentine, and, more rarely, leeches, have been used as 
local applications in the acute stage of pain ; chloroform, stimulating liniments, 
blisters, and iodine, at later stages, when pain was not removed. Blood-letting 
has been used in two cases by Dr. Gairdner, and in two or three more before the 
patient's admission. All that were bled did well, but Dr. Gairdner seldom sees 
cases early enough, and acute enough, and in sufficiently robust individuals, to 
justify the use of this remedy ; in which, nevertheless, he has by no means lost 
faith, believing it to be both very useful in fit cases, and very apt to be made a 
bad use of in incautious hands. Stimulants, and especially ethereal stimulants, 
have been freely used in cases in which the vital powers seemed in danger of 
failing ; and that, whatever the treatment in other respects may have been. He 
has, however, never given stimulants very largely, or as a matter of routine, or 
of aliment ; almost never in slight cases, or in the early stages of the disease ; 
and very rarely indeed to young persons, or those not habituated to the use of 
alcoholic drinks. Food has been given simply according to the patient's powers 
of digestion ; neither withheld nor pressed : in the febrile period, bread and milk, 
or beef-tea with arrowroot, or both ; during convalescence, a diet more gene- 
rous and varied, but not overstimulating. In all cases of doubt and difficulty, 
Dr. Gairdner says he has uniformly adopted the principle, that nature is to be 



I860.] Medical Pathology and Therapeutics. 



23? 



trusted to a great extent ; believing that patients will recover much better and 
sooner under no treatment at all, than under a routine treatment blindly en- 
forced ; or, in other words, that nature is a better manager than a bungling phy- 
sician, who has always an inexorable system in hand to control her operations. 

14. Typhus and Typhoid Fevers as seen in Dublin. — Dr. Hexey Kexxedy 
read before the Eoyal Medical and Chirurgical Society, May 22d, 1860, a paper 
on this subject, an abstract of which we give with a report of part of the discus- 
sion to which it gave rise, as the subject is one in relation to which there still 
exists a difference of opinion. 

The object of Dr. Kennedy's communication was to show that while these 
types or varieties might, in the great majority of instances, be distinguished the 
one from the other, they were still but the results of a common poison. To the 
distinctive marks between the two varieties he had drawn attention, in the Dub- 
lin Medical Journal, as far back as the year 1837, three years before the ap- 
pearance of Dr. Stewart's memoir. The arguments for the identity of the poison 
the author divided into general and special. Amongst the former he particu- 
larly dwelt on the fact of different types of fever coming from the one room ; such 
as cases with and without spots, or some with dark and others with rose spots, 
or the conjestive, nervous, and gastric fevers all existing in one family and at the 
same time. Amongst the special arguments the details of some cases were given 
where petechias existed together with ulcerated bowels ; and also cases of the 
same variety where the two rashes were mixed. The author also noticed the 
fact that intestinal hemorrhage was at least as common in typhus as in typhoid 
fevers — contrary to what is usually thought. In conclusion the author glanced 
at the views now held by many on the stimulant treatment of acute disease. He 
observed that the extent to which these doctrines were carried elsewhere had 
not reached Dublin, nor did he think they would : and he considered there were 
many points, directly involving the general question, which yet required the 
fullest consideration. Though the author did not enter at all on the general 
treatment of fever, he spoke of a few points having a special reference to the 
treatment of typhoid fever. In particular he drew attention to the necessity for 
making a distinction between the stimulants in common use, of which wine and 
beef-tea were instanced. In his experience the effects of the former were much 
less likely to be followed by any unpleasant results than those of the latter: and 
this he had remarked not only in fever, but also in some of the phlegmasia?. The 
cause of this difference Dr. Kennedy attributed to the difference in the consti- 
tuent parts of the two fluids. To the carbonate of ammonia he also directed 
attention, as being in general use ; and yet, in his experience, he had found it 
very apt to cause diarrhoea, and latterly had entirely given it up. The medicine 
he now placed the most reliance on was the dilute sulphuric acid ; and he had 
arrived at this conclusion after having tried the ordinary astringents. The acid, 
however, was not a new remedy. With the acid he always joined local treat- 
ment, such as leeching and. blistering ; nor of its efficacy — when used with ordi- 
nary discretion — had he the slightest doubt, notwithstanding all that had been 
recently urged against it. In the last place, the author spoke of a certain class 
of cases of typhoid fever in which it seemed as if the poison were flitting about 
the system, at one time attacking the abdomen, again the chest, or the brain. 
In such cases he had adopted the expedient of keeping a blister open, usually 
on the chest, for some days ; and from this plan he had seen very marked ad- 
vantage. 

Dr. Stewaet said he was disappointed with Dr. Kennedy's paper, which con- 
tained nothing to overturn the facts and principles laid down by Dr. Jenner and 
other writers, which were now generally accepted by the Profession. It had 
been long known that the petechial eruptions of typhus and typhoid fevers 
might co-exist ; indeed, they were sometimes found in connection with the erup- 
tions of scarlatina and other eruptive diseases. The important point was — Were 
the two eruptions so far identical that they might both become dark, semi-pete- 
chial, then petechial, and not disappearing under pressure ? He had long ob- 
served the phenomena of the two fevers, but had never seen a case in which the 
eruption of typhoid fever had ever, even in extremis, become petechial or even 



23S 



Progress op the Medical Sciences. 



[July 



dark. The last crops of typhoid eruption had been as bright and rosy as the 
first ; while the typhus eruption had a constant tendency as the gravity of the 
case increased to become dark and petechial, and did not disappear under pres- 
sure. He looked in vain in the author's paper for that large basis of fact on 
which his proposition ought to have been founded. 

Dr. MuRGfflSdN said the experience of Dr. Kennedy was totally opposed to 
the experience of the London Fever Hospital for the period of twelve years, 
during which the different forms of fever had been most accurately observed and 
recorded. During that period there had been admitted 4000 cases of typhus, and 
2000 of typhoid fever ; of which about 700 cases of typhus, and 400 of typhoid 
had proved fatal. Most of them had been examined after death, and in no one 
instance had it occurred that the characteristic eruption of typhus fever had been 
observed during life, and the characteristic lesion of typhoid fever had been ob- 
served after death ; while, on the other hand, in no instance had the character- 
istic eruption of typhoid fever been observed during life, and the characteristic 
lesion of typhoid not been found after death. He had observed the phenomena 
of the diseases in Dublin and Edinburgh, where his experience had been of a 
similar character. Some persons imagined that if. in a case of fever, diarrhoea 
appeared as a complication it was necessarily typhoid ; and that the appearance 
of petechia? indicated the existence of typhus. There could be no greater 'mis- 
take. Typhus fever was not unfrequently complicated with diarrhoea; in the 
Crimea it was often complicated with dysentery; but in no instance was typhus 
fever, so complicated, attended with ulceration of Peyer's glands, as proved 
after death. Petechial eruptions were not characteristic of typhus, but oc- 
curred in many diseases which were not idiopathic fevers, being entirely dis- 
tinct from the true bulloid or mulberry rash in typhus fever. Dr. Kennedy had 
lately recorded a case in which he stated that the rash of typhoid fever was 
observed during life, but there was no ulceration of Peyer's patches after death. 
The description, however, which he gave of the eruption was a description not 
of the eruption of typhoid, but of typhus fever. The typhus eruption came out 
all at once, within a period of one or two days, and continued during the whole 
length of the fever, getting darker every day ; while the typhoid eruption came 
out in successive crops, or instead of becoming (as the author stated) converted 
into petechias on the fourth day, the characteristic eruption of typhoid fever 
was by that time disappearing. The occasional co-existence of the two erup- 
tions no more proved the identity of typhus and typhoid fever than the co-exist- 
ence of the eruptions of typhoid fever and scarlatina, which he had observed in 
seven or eight cases, proved the identity of those diseases. 

Dr. Jexxer said he had, since 1846, paid great attention to this subject, and 
for six or seven years had spent six or eight hours daily in the Fever Hospital, 
making as careful a record as he could of each case that came before him. He 
had seen a good deal of fever since, and his latter experience confirmed the con- 
clusions he had drawn from his earlier. He remembered Dr. Bennett being at 
the Hospital, and pointing to a case, he said laughingly, " Do you think you can 
tell from that eruption what the ulceration in the abdomen will be ?" He (Dr. 
Jenner) said he though he could ; and, the case proving fatal, his prediction was 
verified. The condition of the intestine could in every case be predicted from 
the nature of the eruption. Petechial eruptions were found in severe cases of 
erysipelas, smallpox, and scarlet fever, but that was no proof that those diseases 
were identical. The author stated that the disease should be studied all over 
the world, and it had been. Dr. Parkes had observed it on the banks of the 
Bosphorous, and he stated that the distinction between typhus and typhoid 
fevers was recognized by the Turkish physicians. In America, the same dis- 
tinction was made, as appeared by a report of Dr. Flint's on the subject. It 
was not generally believed, as Dr. Kennedy supposed, that typhoid fever was 
symptomatic of intestinal lesion. Many of the early cases which he (Dr. Jen- 
ner) published, were designed to show that the fever and the lesion bore no rela- 
tion in severity to each other. A patient might die of virulent smallpox almost 
before the eruption appeared ; and death might occur from the general disturb- 
ance in typhoid fever with very little intestinal lesion. 

Dr. Wilks said that on the publication of Dr. Jenner's series of cases, ten or 



I860.] 



Medical Pathology and Therapeutics 



239 



eleven years ago, he commenced studying the subject afresh in Guy's Hospital 
— not. perhaps, altogether unprejudiced, for he had been taught by Dr. Addison 
to believe that the two diseases were identical. For three years he noted all the 
cases, and made numerous post-mortem examinations, and he could not avoid 
coming to the conclusion that the two diseases were altogether distinct. The 
anatomical difference — namely, the presence of the lesions in the one case, and 
their absence in the other — would be sufficient of itself to establish the distinc- 
tion. He had remarked that the number of cases in which there was a difficulty 
in diagnosing between typhus and typhoid fever was less than the number of 
cases in which it was found difficult to diagnose between fever and chest, or 
lung, or head disease. In either case, however, the post-mortem appearances 
were decisive as to the nature of the disease. In some instances there was no 
doubt considerable difficulty in deciding between typhus and typhoid fevers dur- 
ing life. 

15. Diseased Supra-renal Capsules unconnected ivith Bronzed Skin. — E. Cross- 
hair Esq.. exhibited before the Bath and Bristol Branch of the British Assoc., 
April 26, 1860. the supra-renal capsules taken from a patient who during life 
exhibited no sign of bronzing of the skin. These bodies were totally disorgan- 
ized and converted into empty cavities, the walls of which were coated inter- 
nally with a thin layer of yellow cheesy matter. 

The subject of the case was a tall thin gardener, aged 59, who became Mr. 
G.'s patient ten days before his death. In the course of last summer, without 
apparent cause, his strength gradually failed him. so much so. that he was com- 
pelled to give up his occupation. Soon after this, a severe and protracted diar- 
rhoea still further reduced his strength and flesh. A few weeks later, anorexia 
and vomiting crept on by degrees, accompanied by dull weight and pain at the 
epigastrium ; added to which, at a later period, was a distressing sense of pul- 
sation in the same situation. "With these prominent symptoms — viz., progressive 
prostration, emaciation, anorexia, and vomiting — extending over a period of eight 
months, he gradually sank. 

At the post-mortem examination, thirty hours after death, the skin presented 
no appearance of bronzed colour, but was of a bright yellowish white. The 
mucous membranes were everywhere anaemic, and the whole body was extremely 
emaciated. The lungs were healthy in substance, but externally of a dark gray 
colour, and bound down by numerous old adhesions. The heart was very large, 
thickly covered with fat. and one segment of the mitral valve was hard and 
thickened. The chylopoietic viscera were healthy, as were the kidneys, liver, 
and spleen. The pancreas was not enlarged, but very hard, and coloured black 
externally. Many of the mesenteric glands presented a condition similar to that 
of the pancreas, being very hard, and coloured externally black. Some parts 
of the liver and kidneys were also stained externally black ; but whether this 
may not have been a post-mortem stain, I am not prepared to say. — British Med. 
Journ. May 12, 1860. 

16. Contributions to the Pathology of Diabetes Mellitus. By Eud. Leubus- 
chee. — The following are the results obtained by Professor Leubuscher and Dr. 
Passauer from a series of experiments on the influence of various articles of diet 
in a case of diabetes mellitus upon the secretion of sugar, urea, and chloride of 
sodium, and upon other circumstances : — 

1. The temperature of the skin was throughout below the average : it was 
generally only 35° C, and even under the influence of an acute affection, which 
ultimately caused the patient's death, it did not exceed 36° C. Diet appeared 
to influence the variations less than the temperature of the room. 

2. The quantity of urine did not correspond to the quantity of liquid drunk, 
but exceeded it materially. On one day when six ounces of red wine, three 
ounces of rectified spirits, and 1000 cubic centimetres of water were taken, the 
quantity of urine amounted to 3300 cubic centimetres, or less than usual. The 
tendency of the patients to deceive in these matters renders the fact less trust- 
worthy. 

3. With a mixed diet and preponderance of starchy diet with much water. 



240 



Progress or the Medical Sciences. 



[July 



the quantity of chloride of sodium and urea secreted exceeded the average ma- 
terially. 

4. A preponderance of animal food increases the quantity of urea secreted, 
and diminishes the amount of sugar without material alteration of the chloride 
of sodium. 

5. A free use of milk with mixed diet produces no change in the relative pro- 
portions of the sugar, chloride of sodium, and urea. 

6. Alcoholic beverages, with chiefly proteinaceous diet, increases the secretion 
of sugar materially and diminishes the urea, the chloride of sodium remaining 
unaltered. 

7. Iron given in the form of the lactate from the middle of November to the 
middle of December, in doses of four to six grains, left the sugar at the average 
quantity, produced no effect upon the urea or chloride of sodium, the patient 
feeling generally well. 

8. Pepsin taken from the middle of December to the beginning of January, 
twice daily, in ten grain doses, diminished the quantity of urine ; the specific 
gravity rose to 1.044 ; all the constituents, sugar as well as urea and chloride of 
sodium, were relatively as well as absolutely increased. The general health of 
the patient continued good. 

9. Benzoin, in the form of benzoic acid, benzoate of soda, or ammonia, taken 
for a month daily in doses of six to eight grains, produced no material influence. 

Acute symptoms of pulmonary disease, gastritis, and enteritis, resulting from 
a cold, supervened, during which albumen appeared in the urine, and the patient 
died comatose on the fourth day of the attack. From the post-mortem account 
we merely extract the remarks that the vessels of the meninges, and especially 
the longitudinal sinus, contained an emulsified liquid in which were red coagula. 
A close examination of the blood exhibited much free fat and white blood-cor- 
puscles, with a considerable quantity of sugar. — Brit, and For. Med.-Chir. Rev., 
April, 1860, from Archiv fur Path. Anat., Bd. xviii. 

17. Diagnosis of Phthisis by the Microscope. — Dr. F. J. Beowx exhibited at 
a meeting of the Southeastern Branch of the British Med. Association (March 
30, 1860) some specimens of pulmonary tubercle prepared by Dr. Andrew 
Clark, of London, which show the presence of the elastic trabecular of the air- 
vesicles and furnish evidence of the destruction of the lung tissue. He also 
gave a summary of the views of Dr. Clark. 

"A few years ago," he remarked, "the pulmonary trabecular were discovered 
in the sputa in phthisis by Schrceder van der Kolk and by Dr. Andrew Clark, 
independently of one another. The former considers, or did consider, the exam- 
ination of the sputa valuable only early in phthisis, whilst Andrew Clark holds 
that the examination is useful at all periods, as being the only certain means of 
detecting the disintegration of the lung and the increase of the disease. It is a 
fact that the disease often increases whilst the patient is getting fat and appears 
sufficiently well to deceive himself, his friends, and his medical attendant. 

The views of Dr. Andrew Clark, briefly expressed, are as follows : — 

1. The parietes of the air-vesicles are indivisible: that is, they cannot be 
separated into layers. They are made up of membrane with bloodvessels, and 
yellow elastic tissue arranged as trabecular. 

2. The air-vesicles are lined by scaly epithelium. The epithelium is easily 
demonstrated in the child : it is more difficult of demonstration in advanced life. 
It plays an important part in all chronic structural lesions of the lungs. It is 
absent in emphysema. The existence of an epithelium of the air-vesicles is 
denied by Bowman, Eainey, and Beale. They admit the appearance of cell-par- 
ticles in the air-vesicles, but they believe them to be only the nuclei of the capil- 
laries. They admit, also, the presence of nucleated cells that cannot be ascribed 
to the capillaries, but they believe them to be the product of morbid action. Dr. 
Clark's reply is, that no lung is found without them. 

3. Previously to the tuberculosis there is a disorder of the assimilation, which 
may be termed pretubercular cachexia. 

4. Phthisis commences with the deposit of tubercle, and is a term common to 
all the stages of pulmonary tuberculization. Phthisis is the name assigned to a 



I860.] Medical Pathology and Therapeutics. 241 

certain anatomical lesion of the lung, and is to be understood in a different sense 
to that in which the older physicians regard it; for with them phthisis is hectic 
fever arising from pulmonary tuberculization. Phthisis, in the language of most 
practitioners, consists of hectic fever due to softened tubercle in the process of 
elimination. This is symptomatic phthisis. Anatomical phthisis, so to speak, 
consists in the lesion of the lung, whether attended or not by hectic fever. The 
distinction resembles that made betwixt the pneumonia before Laennec's time 
and that pulmonary lesion recognized as pneumonia subsequently to the intro- 
duction of auscultation into practice. 

5. Elimination of softened tubercle is the third stage of phthisis, and may go 
on in one part whilst deposition occurs in another; consequently, there is a 
mingling of the stages of phthisis — regarding this disease in an anatomical light . 

6. Tubercle is a retrograde metamorphosis of the structural elements and of 
the fluid secretions (if there be any) of the part in which it may be found. 
Tubercle is not a deposit from the blood, but is a product of vitiated nutrition — 
not a simple exudation, but a complex result of perverted vital action. When 
tubercular matter accumulates and presses upon the bloodvessels, it may excite 
irritation, in which case congestion is not unfrequently set up, which terminates 
in an exudation, which becomes mixed with the tubercular matter, and after- 
wards tuberculizes. Such exudation in the first place is just like the exudation 
that takes place on an inflamed pleura; but the exudation being placed under 
unfavourable circumstances, does not become developed into a tissue, but 
degenerates into tubercle. 

7. The air-vesicles are the seat of tubercle in the lung. 

8. When the tubercular matter accumulates to such an extent as to compress 
the walls of the air-vesicles, the entire structure of the walls disintegrates, except 
the elastic trabecular (which are alone characteristic of the air vesicles). 

9. The elastic trabecular are seen in the sputa, lying in disorder amongst the 
disintegrated elements of the tissue, and are readily detected by the aid of the 
microscope. 

10. The elastic trabecular are present in the sputa during the elimination of 
the tubercle, and constitute the diagnostic mark of the eliminative stage. 

11. If elimination takes place with only minute deposit in the lung, the micro- 
scope will reveal the disease sooner than the pleximeter and stethoscope ; but 
where there is a considerable mass of tubercle in the lung, without elimination 
of any portion, percussion and auscultation, taken in connection with the general 
symptoms, will detect the disease, whilst the microscope gives negative results. 
Again, minute deposit in a quiescent state will be overlooked, although both the 
ear and the eye be employed for its detection. 

12. The physician can confidently declare that phthisis exists when he finds 
the elastic trabecular in the sputa. 

13. Phthisis commences with the deposit of tubercle, and tends to one of two 
issues: — (a) to recovery by absorption, by calcification, or by induration and 
pigmentary transformation ; (5) or to suppuration and the establishment of 
hectic fever. 

14. It is yet uncertain whether recovery or progressive disease be the more 
frequent. 

15. The air-vesicles may remain filled with tubercle in a state of complete 
quiescence, without softening or elimination, for years. This is a state of things 
that the microscope will not determine. It must be worked out by the study of 
symptoms and of auscultatory signs. 

16. The parietes of the air-vesicles remain intact in phthisis until one or other 
of the following events happen, (a) The tubercular matter accumulates to such 
an extent as to compress the walls of the air- vesicles with such force as to empty 
or obliterate the capillaries, when, nutrition being suspended, disintegration 
ensues, and the tubercular matter in one vesicle comes in contact with that in 
the adjoining vesicle, and so the two masses cohere, (b) The tubercular matter 
softens from any cause, (c) The tubercular matter sets up pneumonia, which 
breaks down the whole mass. 

17. The elastic trabecular of the air-vesicles cannot be confounded with any 
No. LXXIX.— July 1860. 16 



242 Progress of the Medical Sciences. [July 

other yellow elastic tissues likely to be found in the sputa, because of their cha- 
racter and arrangement. 

18. Tubercle is often found in the tonsils ; and the elongated cells of the tonsil- 
tissue, arranged as they are in an areolar form, might mislead an inexperienced 
observer. A little attention will obviate this apparent difficulty. The quasi- 
bands seen in sections of the tonsils consist of separate pieces, easily recog- 
nized as being separate, whereas the pulmonary trabecular are continuous and 
wavy. However, the distinction is made certain by chemical tests. The pulmo- 
nary trabecular resist the action of both acetic acid and liquor potassae (inasmuch 
as they consist of yellow elastic tissue,) whereas the elongated tonsil-cells resist 
acetic acid only, and yield to liquor potassae, which renders them invisible. 

19. The microscopic examination of the sputa enables us to detect softening 
tubercle in the progress of elimination, which could not otherwise be detected ; 
it confirms or corrects the diagnosis between phthisis, dilated bronchi, chronic 
bronchitis, etc. ; and it determines the actual progress of the lesion of the lung. 

Thus it is seen that the microscope confirms the opinion of the vulgar as 
respects " the spitting up of the lights," which is now an undoubted fact. 

In conclusion, allow me to state my conviction that the detection of the yellow 
elastic tissue of the air-vesicles in the sputa is one of the great discoveries ren- 
dered to pathology by the microscope. The importance of being aware of the 
true state of matters in any given case, cannot be overrated ; and I am sure that 
you will allow that when once we can pronounce a man to be under phthisis 
(using the term in the anatomical sense), we are likely to use hygienic and thera- 
peutic means with greater precision and with greater prospect of success than 
if we considered the case to be one of catarrh, simple dyspepsia, or that mon- 
strum horrendum ' debility.' " — British Med. Journ., April 21, 1860. 

18. Condition of the Blood in Ma.nia. — Dr. W. C. Hood read before the Royal 
Medical and Chirurgical Society (May 8, 1860), a paper on this subject. The 
researches of Drs. Hittorf and Erlenmeyer, tend to show that in acute mania. 
there is a diminution in the amount of fibrin in the blood. Dr. Hood, aided 
by Dr. Marcet, with a view of elucidating this subject, has been induced to make 
careful analyses of the blood of six maniacal patients, during the paroxysm and 
in a state of convalescence, which induce him to think that the facts arrived at 
(not before indicated) show, that there is a marked deficiency of fibrin during 
the period of maniacal excitement, and a correction of this deficiency during 
convalescence. The blood was drawn by cupping at the nape of the neck to the 
same amount in each case, and immediately collected in earthenware pots con- 
taining about two ounces each ; and it was in every instance within a few hours 
of extraction subjected to the same method of analysis. The six cases selected 
were three of " acute" and three of " recurring mania." 

19. Abscess in the Iliac Fossa in Children. — M. Bouchut states that iliac 
abscess is rare except in the puerperal state ; and especially rare in children. 
It may be consecutive to inflammation of the caecum, or may be produced by 
foreign bodies perforating the caecal appendix. Sometimes the iliac abscess 
arises from psoritis, or from laceration of the psoas muscle. But the proof 
that this abscess is most commonly produced by foreign bodies, is afforded by 
its almost constant occurrence in the right side, in the neighbourhood of the 
ileo-cascal appendix. Of fifty-seven non-puerperal iliac abscesses collected by 
M. Grisolle, nine only were on the left side ; while, of twenty-six puerperal 
abscesses, fifteen were on that side. These inflammatory tumours are some- 
times situated in the peritoneum, in front of the caecum ; in other cases, they 
are beneath the peritoneum, and even under the aponeurosis. The intraperi- 
toneal tumours are generally superficial; they depress the caecum, and impede 
the passage of feces. When situated behind the caecum, as in the first of the 
two cases related above, they are sometimes very difficult of detection. The 
phlegmasiae of the iliac fossa manifest themselves sometimes without premonitory 
symptoms, sometimes after a rigor ; there is always severe pain, resembling that 
of peritonitis. M. Bouchut is of opinion that, by energetic treatment in an 
early stage, suppuration maybe obviated. If pus is formed, it may be discharged 



I860..] 



Surgery. 



243 



in various directions. When the abscess is superficial, it may open outwardly ; 
if adhesions have been formed between the intestine and the abscess, this may 
open into the intestine. M. Grisolle and M. Bouchut have each seen a case in 
which the abscess has opened into the vagina ; in other cases the abscess may 
open into the bladder or peritoneum. Of fifty-six non-puerperal cases collected 
by M. Grisolle, thirteen were fatal. The treatment according to M. Bouchut, 
should consist in the early and repeated application of leeches. If the touch 
indicates the presence of pus, an incision should be made parallel to Poupart's 
ligament down to the peritoneum. An exploratory puncture having been then 
made, the incision is to be enlarged, if pus is present ; and the wound should 
be kept open by lint, over which a poultice is to be applied. If the abscess is 
deep-seated, the treatment should consist in the use of emollients and baths, so 
as to assist the efforts of nature at elimination. If there be a tendency to indu- 
ration, flying blisters maybe applied; although M. Bouchut. does not think that 
they are so efficacious in cases of suppuration as has been supposed. — Journ. 
de Med. et de Ghirurg. Prat., Oct. 1859. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIYE 

SURGERY. 

20. Treatment of Axillary Aneurism. — A paper on this subject was read 
before the Royal Medical and Chirurgical Society, April 24, 1860, by Mr. Syme, 
of Edinburgh. The object of it was to suggest that in general, if not always, 
the old operation would be preferable to the method of Hunter for the treatment 
of axillary aneurism. "With the view of supporting what might appear rather 
startling doctrine, the author combated the generally received opinion that the 
portion of an artery comprehended by an aneurism is not competent for the pro- 
cess of obliteration by ligature, and maintained that the mere circumstance of 
isolation from neighbouring connections while the vessel still retained its usual 
relation to the sheath should not render it unfit for the process in question. In 
favour of this position, he quoted the successful result of ten operations per- 
formed by him in the old way for the remedy of traumatic aneurism at the bend 
of the arm, and also the remedy by the same means, of a carotid aneurism too 
low in the neck for ligature without opening the sac, which, if allowed to pro- 
ceed, would have proved fatal, not only to the patient, but to his assailant who 
inflicted the wound, and who would certainly have been hanged in the event of 
its proving fatal. The author further related two cases of axillary aneurism, 
not admitting of relief from ligature of the subclavian, in which amputation at 
the shoulder-joint was performed with success. But the principal ground of his 
suggestion was a case of axillary aneurism which had lately come under treat- 
ment in the Royal Infirmary of Edinburgh. The tumour was very large, distend- 
ing the muscles of the axilla, and projecting above the clavicle. It was rapidly 
increasing, and already showed signs of impending gangrene ; while the patient's 
general condition, as manifested by a pulse of 130, and wandering ideas, was no 
less alarming. Ligature of the subclavian being quite out of the question, before 
proceeding to amputation at the shoulder-joint it was deemed proper to ascer- 
tain the state of matters in the axilla. But as this could not be done without 
the risk, or rather certainty, of a fatal hemorrhage, unless the artery could be 
commanded in the first instance, an incision was made along the posterior edge 
of the sterno-mastoid, through the platysma myoides and fascia, so as to allow 
the finger of an assistant to reach the vessel where it issues from under the edge 
of the scalenus anticus and lies upon the first rib. The cavity was then opened, 
nearly seven pounds of coagulated blood removed, and both ends of the artery 
tied, as it was found to have been torn across. The patient made a good recov- 
ery, and was dismissed six weeks after the operation, able to resume his employ- 
ment. The old operation, having thus succeeded in a case so formidable and 
unpromising, seemed worthy of adoption, not merely in cases unsuitable for liga- 



244 



Progress of the Medical Sciences. 



[July 



ture of the subclavian, but as preferable to the Hunterian method, on account 
of its greater facility, safety, and certainty. The author, having upon two occa- 
sions tied the subclavian artery for aneurism with perfect success, had no preju- 
dice against this operation, but was forced to the conclusion just expressed by 
his sincere conviction of what was due to expediency. He also begged to sug- 
gest that the means employed for effectually commanding the artery, perhaps 
admitted of more extensive application. It had been used by the author thirty 
years ago in his first operation for the removal of the superior maxillary bone, 
in which excessive hemorrhage had been erroneously anticipated, by making an 
incision between the ramus of the jaw and mastoid process, so as to admit a 
finger to compress the internal maxillary artery on the neck of the condyle. 
The author remarked that in this case the superior maxillary bone was removed 
for the first time in Great Britain, and that the operation is the earliest to be 
found in the records of surgery. 

Mr. Erichsen said every one must admire the skill with which the operation 
described by Mr. Syme had been performed; but he could not look upon the 
case as influencing in the slightest degree the application of the Hunterian 
principle in the treatment of aneurism. It appeared to him that the author of 
the paper had not made any distinction between traumatic and spontaneous 
aneurism. With regard to the former occurring at the bend of the arm and 
elsewhere, Mr. Syme, like other surgeons, had been in the habit of laying them 
open. No surgeon would think of ligaturing the brachial artery for aneurism 
at the bend of the arm, resulting from venesection, but he would lay it open and 
ligature the artery on either side. Mr. Syme's case appeared to have been a 
traumatic, rather than a spontaneous, aneurism ; and surgeons could not be too 
careful how they endeavoured to apply to the latter the principles of treatment 
applicable to the former. Had the case been one of spontaneous aneurism, the 
tumour would not have been of such rapid formation, nor would there have been 
so entire a disruption of the artery. Mr. Guthrie, in his work on "Injuries of 
Arteries," had pointed out in the clearest manner that in all cases of diffused 
aneurism in the axilla, the line of practice adopted by Mr. Syme in the present 
case should be carried out. He severely criticized the practice of ligaturing the 
subclavian artery above the clavicle for diffused aneurism in the axilla, and 
stated that the proper course was to lay the tumour fairly open, to cut through 
the pectoral muscles, and ligature the artery where it was injured. Such a 
course would be highly objectionable in spontaneous aneurisms. He did not 
believe that the disease was limited to the spot that became aneurismal. In the 
first case in which the subclavian artery was tied in this country (by Mr. Listen) 
it was described to be like the finger of a wet glove, and the patient died of 
secondary hemorrhage in consequence of the diseased state of the coats of the 
artery. He (Mr. Erichsen) had generally found extensive traces of disease in 
other parts of the arterial system besides that which was aneurismal ; and in 
some cases disease was found at the same spot in the opposite side of the body. 
It was incumbent on them to be very cautious how they attempted to overturn 
a principle of surgery established for seventy years by the practice adopted, 
successful though it might be, in any one case. The last cases to select for the 
subversion of the Hunterian principle were those of axillary aneurism. They 
differed from other aneurisms in being much more liable to become diffused and 
to run into a state of suppuration and slough, which explained the reason why 
the practice of ligaturing the subclavian artery above the clavicle in spontaneous 
axillary aneurisms had not been so successful as the same treatment had been 
in the case of aneurisms elsewhere. — Med. Times and Gaz., May 5, 1860. 

21. New Method of Effecting the Radical Cure of Hernia. — Mr. John Wood 
read before the Eoyal Medico-Ohirurgical Society (Feb. 28, 1860) a description 
of this operation. He commenced by giving a brief sketch of the anatomy of 
the inguinal region. The peculiarities of structure of the parts concerned in 
inguinal hernia, of which especial advantage is taken in the operation proposed 
and practised by the author, are : 1. The mobility and sliding power of the skin 
in the groin, owing to the synovial character and loose areolar meshes of the 
deep layer of superficial fascia; 2. The total absence of fat from the areolar 



I860.] 



Surgery. 



245 



tissue of the scrotum, its density, elasticity, toughness, and great vascularity 
enabling the surgeon to invaginate it into the inguinal canal, to retain it there 
by stitches, and cause it permanently to adhere to its sides and to the cord ; 3. 
The protection afforded to the peritoneum and vessels (epigastric and circumflex 
iliac) by the intervention of the fascia transversalis, and its connection with the 
deep surface of Poupart's ligament; 4. The formation by the conjoined tendon 
of the internal oblique and transversalis muscles and triangular ligament of the 
greater portion of the posterior wall of the canal, and the feasibility of raising 
the former by the finger passed into the canal behind the lower edge of the 
internal oblique muscle, so as to pass a needle through it and the internal pillar 
of the external abdominal ring together. The author then stated that the me- 
thods respectively practised by Ragg, Bonnet, Gerdy, and more lately by Wutzer, 
of Bonne, and Kothenmunde, of Munich, most frequently fail in producing a per- 
manent cure chiefly by their not obtaining a hold upon the posterior wall of the 
canal, and their securing only the anterior portion of the fold produced by 
invagination, leaving the posterior half of the fold ready for the reception of a 
fresh portion of intestine. The objections to the introduction of a hard dilating 
plug into the invaginated fold of skin and its retention, by Wutzer's method, 
are as follows : That the skin and fasciae intervening in two layers between the 
compressing hard surfaces and the serous laminae of the invaginated sac, ward 
off from them in a great measure the effect intended — namely, that of adhesive 
inflammation; while the absence of counter-pressure behind the posterior fold 
renders the dilating force of the plug almost nugatory, unless sufficient expanding 
power to cause sloughing be employed, to the great distress, not to say danger, 
of the patient. The dilating action of the plug upon the canal and external ring 
leaves the latter in a worse condition than before in case of the failure of the 
operation. The principle of plugging up a dilatable aperture like the inguinal 
opening is surely a false one. The invaginated skin invariably descends when 
the consolidation is absorbed, the latter being temporary only in its duration. 
The principle of the author's operation is directly opposite to that of dilatation 
— namely, that of drawing together and compressing the anterior and posterior 
walls of the canal in its whole length, and their union by the adhesive process 
with the invaginated fascia of the scrotum, which is detached from the skin and 
transplanted into the canal, the skin being left to adhere below to the approxi- 
mated margins of the external abdominal ring. By this means the posterior 
wall of the inguinal canal is made to act as a valve to prevent any future descent 
of the bowel, shutting up the superior opening by becoming united to the ante- 
rior wall through the medium of the scrotal fascia, which thus affords a very 
highly organized and vascular connective tissue between the tendinous surfaces, 
which it would be very difficult to cause to adhere together otherwise. The 
fascial invagination becomes likewise firmly adherent to the spermatic cord. 
This continues to be effective even when the temporary effusion of lymph is 
reabsorbed. 

The Operation. — This consists : 1. In detaching the scrotal fascia from the 
skin over the lowest part of the hernial protrusion with a tenotomy-knife, and 
then invaginating the fascia into the canal with the forefinger. 2. In passing a 
strong, well-curved needle, fixed in a handle, armed with a stout, thick thread, 
and guided by the finger, through three points in the canal — viz., the conjoined 
tendon and the triangular fascia (forming the posterior wall), and the external 
pillar of the ring close to Poupart's ligament (forming the anterior wall of the 
canal). The ends of the ligature are left in the two former punctures, and a 
central loop in the latter, passing through the pillars of the external ring, and 
through the same aperture in the skin of the groin. This may readily be done 
by sliding upon the adjacent aponeurosis. 3. A cylindrical or flattened compress 
of glass or boxwood, two inches and a half long by one inch wide, is tied firmly 
upon the axis of the canal by passing the ends of the ligature through the loop, 
and tying over the compress. Before tightening the ligature, the surgeon should 
satisfy himself, by passing the forefinger through the external ring, that the liga- 
tures draw upon the posterior wall. The opening in the scrotum should be 
tucked well up to, but not within, the external ring. In recent cases of hernia, 
in which the sac is small and possesses an intimate vascular connection with the 



246 



Progress of the Medical Sciences, 



[July 



peritoneum, and a very slight one with the cord, it maybe pushed back into the 
superior opening, and the ligature applied altogether external to and without 
puncturing the sac. thus diminishing very much the chances of peritoneal in- 
flammation. But in old and large hernias the sac has a more intimate vascular 
connection with the scrotum and cord, and constitutes, as it were, a separate 
structure, distinct from the peritoneum. In these cases the sac is necessarily 
invaginated with the fascia, and the ligatures pass through it. In these the 
inflammation set up in the sac is much less liable to spread into the abdominal 
cavity, especially when the upper orifice is closed by the ligature. In a large 
sac the adhesive process is necessary to complete obliteration of the canal, and 
to prevent future complications. The compress is removed from the fourth to 
the seventh day. according to the degree of action set up. The ligatures may 
be left in a week or two longer, to act as conductors for the discharges, and to 
keep up consolidating action as long as may be desirable. When the sac is 
punctured, serous fluid flows from the wound in greater or less quantity during 
the first three or four days. The author called attention to the action of the 
rectus muscle upon the inguinal canal through the conjoined tendon, in drawing 
backwards the posterior wall of the hernial canal, thus aiding the dilating action 
of the protruding bowel in the production and growth of the hernia. The effect 
of the ligatures and consequent adhesions in his operation directly counteracts 
this action of the rectus. He considers that the first tendency to oblique ingui- 
nal hernia, so often hereditary, is owing to deficient development of the lower 
fibres of the internal oblique producing an imperfect covering to the internal 
ring. In some of the cases operated on. he has succeeded in supplementing 
this deficiency by passing the scrotal fascia well up in front of the internal 
abdominal ring, and securing it to Poupart's ligament in that position. He 
considers that the chief source of failure in the performance of his operation, 
especially in large and old cases, is in not securing a hold upon the posterior 
wall. By simply attaching the fascia to the pillars of the external ring, and 
drawing the latter together, the hernia, though prevented for a time from de- 
scending into the scrotum, still occupies the canal, and will, sooner or later, 
again dilate the external ring, unless constantly bolstered up by a truss. The 
closing of the external ring by the lower ligatures, in this operation, contributes 
much, however, to secure in its new position in the canal the transplanted fascia. 
In small cases of direct hernia the closure or obliteration of the external ring 
only may be effective in producing a cure, if care be taken to obtain a hold with 
the inner end of the ligature upon the triangular fascia covering the border of 
the rectus, immediately behind the opening of the external ring. In noticing 
the objections to the plan, the author showed that, by properly protecting the 
point of the needle with the finger, and keeping in front of the fascia trans- 
versalis, all danger of wounding the epigastric and circumflex iliac vessels or 
the bowel was guarded against. The fear of peritonitis is avoided in recent 
cases (in which it is most to be dreaded) by not puncturing the sac at all, but 
closing up the tendinous opening external to it. In old cases, adhesive action 
may be set up in the sac without fear of its spreading to the peritoneum, as the 
results of numerous cases have shown. The objections made to the limited 
incision into the skin of the scrotum (which is little more than a puncture) he 
considers to be puerile. Its advantages in permitting the escape of discharges 
are evident. Full reports of fifteen cases of hernia (all inguinal; were appended 
to the paper. One of the cases was a boy of eight years of age: the ages of the 
others ranged from fifteen to fifty-four and fifty-eight years. One was a female 
with bubonocele ; the rest were males. Three were cases of direct, the rest of 
oblique hernia. Thirteen were scrotal ; four of large size, and three with very 
large and lax internal opening's. Two were congenital, and two complicated 
with varicocele (cured also by the operation). In only one case were the symp- 
toms at all severe, or gave suspicion of peritonitis. In this case the patient was 
in King's College Hospital eight weeks, the symptoms were produced by burrow- 
ing of matter between the oblique muscles, following a diarrhoea then prevalent 
in the hospital (in July last). This patient made an excellent cure, was treated 
entirely without truss, and was one of the cases shown to the society. The 
hernia' had a very large internal opening, and the subject was cachectic and 



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247 



ill-nourished before the operation. In one other case the patient was in bed a 
month ; in another there was partial sloughing of the sac, which was a large and 
long one. with a very pendulous scrotum, and a large varicocele. This case was 
treated also entirely without truss, and both hernia and varicocele were cured 
in eighteen days. The duration of treatment in the rest of the cases varied from 
nine to twenty-one days. Eight were treated entirely without truss. Thirteen 
are good and persistent cures, and have remained firm ever since, extending 
over the following periods of time : one (the first), very nearly two years (this 
case was published in the Lancet, of May 29. 1858); another, one year; two, 
ten months ; four, nine months ; three, eight months ; one, two months. Three 
of the cases had been before operated on by Wutzer's and Ragg's methods ; 
one case was operated on twice ; one is doubtful ; one was re-ruptured by indis- 
creet and early hard lifting without truss. Six cases of cure were exhibited by 
the author to the fellows of the society. Of these, four had been treated entirely 
without truss, and all had been well, and some severely, tested by lifting and 
heavy labour. The first case (operated on nearly two years ago) was among 
those exhibited. No difference whatever was apparent between the groins of 
the two sides. One had been cured in a year, three in nine months, and one in 
eight months. One of those treated without truss was congenital, in a young- 
man aged twenty years ; another was of five years' standing, in a man aged fifty- 
eight. The rest were of eighteen, sixteen, and three months' standing respect- 
ively. All were scrotal hernise, and two direct. Two had chronic bronchitis 
(at times severe) after the operation, and one during the progress of the cure. 
The paper was illustrated by diagrams, to which the author directed the atten- 
tion of the fellows. 

22. Mammary Inflammation and Mammary Abscess. — Dr. McClixtock 
read before the Surgical Society of Ireland, April 14th, 1860. some interesting 
observations on this subject. He stated that during the last five years 54 cases 
of mammary abscess have been treated in the chronic wards of the Lying-in 
Hospital. In ten instances both breasts were affected ; in eighteen, the right ; 
and in twenty-six the left breast was exclusively engaged. 

The great preponderance of cases of mammary abscess on the left side is 
somewhat remarkable, especially when taken in connection with the fact that 
other puerperal lesions evince a similar partiality for the same side of the body. 
Can the position on the left side during labour and delivery have anything to 
say to it ? This question we cannot positively answer ; but it is curious that 
in the practice of Yelpeau, at Paris, where all women, as you know, are con- 
fined on the back, abscess occurred with equal frequency in right and left 
breasts. 

A very large proportion of the fifty-four patients had some form of sore nipple 
previously to the occurrence of inflammation of the gland. In nearly all of 
them the inflammation came on days or weeks after the patient had left the 
hospital, or had ceased to be under medical care. On a few occasions, I have 
had an opportunity of observing t$ie inflammation of the breast to supervene 
immediately and directly upon the ulceration or fissure of the nipple. The 
great danger, in fact, to be apprehended from sore nipples, is mammary inflam- 
mation, and this may be considered imminent when the base of the nipple 
becomes hard and tender. Poulticing the nipple and giving it perfect rest are 
the best means of preventing the extension of this inflammation to the substance 
of the gland. 

Let it not be supposed that I regard this as the only cause of mastitis. Far 
from it; but I believe it to be a very influential and a very frequent one. The 
popular notion is, that retention of the milk and the consequent distension of 
the breast, is, in almost every instance, the cause of the inflammation ; and by 
the great mass of practitioners the same notion is too exclusively held. 

This idea may. I think, be regarded as the last lingering figment of the doc- 
trine so strongly held by Puzos and the leading obstetric authorities of his day, 
and even later, which ascribed many puerperal diseases to the morbific action 
of the milk. Hence, puerperal insanity was designated mania lactea ; secondary 
pelvic inflammation, or pelvic cellulitis, was a depot-laiteux ; the effusions into 



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[July 



the belly in puerperal peritonitis were the curd and serum of the milk, and 
phlegmasia dolens was the "milk leg" of this class of pathologists whom ]\Ieigs, 
with contemptuous sarcasm, calls by the name of " the milk men." 

I have very rarely known inflammation and abscess to result from distension 
of the breast alone, and where there was no irritation of the nipple, nor abscess 
in the breast before. Neither do I recollect ever seeing mammary abscess in a 
woman whose child was dead born ; or supervening upon the death of a nurs- 
ling, where no other exciting cause of inflammation was present. And yet in 
both these cases the gland is unavoidably subjected to considerable distension. 
Upon this point Velpeau states : " Attentive consideration of the facts shows, 
in the most unquestionable manner, that women who nurse are more frequently 
affected with abscess than those who do not." 

The bearing of this upon practice is obvious enough — actuated by the notion 
that retention of the milk is the grand source of mischief, we find nurses, and 
patients, and occasionally even doctors, using every means, natural and arti- 
ficial, to "draw the breasts,"' and no ways deterred from doing so by the pre- 
sence of a sore or inflamed nipple ; indeed, this is always considered by patients 
as an additional reason for the more vigorous employment of these exhaustive 
measures, and the natural effect of them, is to insure the occurrence of what is 
so much dreaded. I have no objection to rubbing or suction of the breasts to 
relieve or prevent over-distension, provided the nipple be not sore ; if this be 
the case, however, our first care should be to give it perfect rest, as there is 
more danger of inflammation extending from the sore nipple, than originating 
in the distended gland, and as for the distension of the breast with milk, good 
hand-rubbing and the application of the cere cloth will seldom fail to relieve it. 
Before ordering a breast to be rubbed, it is of the greatest importance to dis- 
tinguish the hardness of simple lacteal distension, from the hardness of incipient 
inflammation. Through inattention to this, I have seen bad abscesses produced 
which might have been prevented. 

The external employment of extract of belladonna has been much praised of 
late for its power of promoting the absorption of the milk. In my opinion, 
however, its efficacy in this way is little superior to the common cere cloth, and 
I speak from the experience of a considerable number of cases where I submitted 
it to the fairest test possible, viz., one breast of the patient was covered with 
the ordinary cere cloth, and the other breast was well coated with extract of 
belladonna. The remedies were thus fairly tried, and in only one or two in- 
stances was there any perceptible difference in the effect of the two remedies ; 
and in these the difference was very slight. The patient herself thought the 
" black breast" was a shade softer than its fellow which had been enveloped in 
the cere cloth. It might be attended with risk to the child to use the bella- 
donna, if the woman were still suckling. 

Velpeau. speaking of chaps or fissures of the nipple, says that the disease 
may extend into the substance of the breast through the lactiferous tubes, or 
into the neighbouring areolar tissue, to such an extent that more than one 
abscess of the breast has been caused in this way. I think he might have gone 
further and said that very many abscesses have thus originated. This author 
does not seem aware of the important part which sore nipples play in exciting 
mammary inflammation ; for in answer to the question, "Should a woman with 
fissured nipples cease from suckling ?" he says, " As a general rule, no ;" but 
he subjoins this prudent advice: "If the disease be obstinate, if the woman 
continue to be much affected, and the child get ill. or fall away, it is better to 
resort to a wet nurse, since that is the only measure which can restore quietness 
and health to both mother and child." 

In our Practical Midwifery, Dr. Hardy and I have laid stress on this same 
point, and all my subsequent experience confirms me in the opinion there ex- 
pressed. The resolvative treatment of mammary inflammation is admitted to 
be very unsatisfactory, rarely effecting the desired end. even though undertaken 
at the very onset of the attack, and carried out with vigour. After free purging, 
the best internal treatment I believe to be the tartarized antimony in nauseating 
doses, as recommended by Dr. Beatty. In the way of topical treatment we 
have a choice between leeching, hot fomentations, mercurial ointment, and cold 



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Surgery. 



249 



lotions, and, after some experience with each of these, I am bound to say that 
the cold lotion has more frequently succeeded than any of the others. At the 
same time I must add that the proportion of cases in which resolution has been 
brought about by its means is very small. The lotion I have been in the habit 
of ordering is composed of muriate of ammonia dissolved in about equal parts 
of vinegar, water, and spirits of wine. Whether the sal ammoniac possesses 
any peculiar or discutient property in these cases I will not pretend to say. Mr. 
Tuson, however, speaks of it in very favourable terms, and says he has seen it 
disperse inflammatory swellings of the breast, even when the presence of matter 
was quite palpable. 

I have notes, of cases where, under the use of the above lotion, resolution 
took place after the formation of a phlegmonous tumour of the breast, attended 
with an erythematous blush on the surface, and the usual pain, tenderness, and 
febrile action of acute mastitis. In nearly every instance, not excepting ihe 
unsuccessful ones, patients have felt a considerable mitigation of the pain by 
the employment of the cold lotion. It is but proper to add, that in two instances 
suppuration had unquestionably taken place ; yet under the use of the lotion 
the matter was entirely reabsorbed. One of these patients had an abscess not 
long before in the same breast. It is rare for mammary inflammation to arise 
before the fifth or sixth day after parturition ; but if it did, I would not, under 
these circumstances, employ the cold, as metastasis might take place to the 
uterus. For the same reason, any treatment that would " repel the milk," or 
rather repel the blood from the mammary gland, is not prudent within the same 
period post partum. 

With regard to the exact time for opening mammary abscesses, there exists 
a difference of opinion among surgeons ; some recommending it to be done as 
soon as the presence of matter is established ; whilst others advise us to wait 
until the abscess is pointing, or the matter immediately beneath the skin. "Per- 
haps," says Cooper, in his Surgical Dictionary, " as a general rule, the surgeon 
should never wait for an abscess of the breast to approach the surface, but 
make an opening as soon as the slightest degree of fluctuation is perceptible ; 
for if this be not done, and the abscess is not very superficial, the matter will 
spread and form sinuses in different directions." On the same point Sir A. 
Cooper thus speaks : " If the abscess be quick in its progress, if it be placed on 
the anterior surface of the breast, and if the sufferings which it occasions are 
not excessively severe, it is best to leave it to its natural course ; but if, on the 
contrary, the abscess in its commencement is very deeply placed, if its progress 
be tedious, if the local sufferings be excessively severe, if there be a high degree 
of irritative fever, and the patient suffer from profuse perspiration and want of 
rest, much time is saved and pain avoided, by discharging the matter with a 
lancet." 

Yelpeau says an early opening is useful in subcutaneous abscess, less advan- 
tageous in the deep-seated or submammary variety, and may even prove injurious 
in the glandular or parenchymatous abscess, which is the only kind where there 
is some advantage in not anticipating, but in giving time for the formation to 
open itself, or at any rate in opening them merely by puncture. 

During an experience of nine years at the Lying-in Hospital, the rule of late 
puncture was the one almost invariably followed, and in every single instance 
with the most satisfactory result. It has been supposed that by delaying to 
evacuate the abscess, its size would of course be increased, and that conse- 
quently the obliteration of its sac would be proportionately slow in taking place. 
In answer to this objection, I can only say that my experience does not at all 
warrant such an apprehension. Nay more, the most rapid cures I have seen 
after lancing the breast, were cases where the matter was so near the surface 
that ulceration was on the point of taking place, and the abscess had attained 
a very great magnitude. A very remarkable example of this kind came under 
observation at the hospital a couple of months ago. A young woman, with red 
hair and fair complexion, who was a few weeks confined, applied for admission 
to the chronic ward on account of an abscess which had been forming for some 
days in the left breast. She was in great suffering, and the breast was enor- 
mously swollen, and very much discoloured. The tumour was most prominent 



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[July 



in the situation of the areola, and all trace of the nipple was effaced. The 
colour of the part was dark and mottled, as though on the eve of bursting, and 
I need scarcely add that fluctuation was everywhere quite distinct. On plung- 
ing a bistoury into the breast, a thick jet of purulent matter was forcibly 
projected to the distance of several inches. In the course of a few minutes 
thirty-six fluidounces (by measurement) of pus were spontaneously discharged. 
This was certainly the largest mammary abscess I ever saw: nevertheless, not 
an ounce more matter was secreted, and this vast sac was entirely closed in the 
space of five days. In this and the other like instances which I have seen, 
strapping the breast with adhesive plaster was employed after the second day. 
It was impossible to know in what part of the breast these abscesses commenced : 
but in each of them the gland was involved, I think, to a greater or less extent, 
at the time the patient was seen. 

Though advocating, as a general rule, the delayed opening of the abscess, still 
I would not go so far as to say it should never be departed from ; for in some 
instances, especially where the collection is sub-mammary, it may be expedient 
to make an early incision on account of severe pain and constitutional irritation, 
or to prevent the burrowing of the matter. The point to select for puncture 
should be as remote as possible from the nipple, so as to lessen the risk of its 
retraction, which but too surely takes place when the opening, whether natural 
or artificial, is within the areola. 

Having had occasion to allude to strapping or compression of the breast. I 
would wish to say a word upon it here. The practice, which MM. Trousseau 
and Contour were the first to introduce, was strongly recommended by them in 
every stage of mammary inflammation. This precept is, perhaps, too universal, 
and leads one to expect too much from the agent. Of its great utility after the 
evacuation of the abscess, and the subsidence of surrounding inflammation, I 
can speak in the strongest terms. When so employed. I have always found it a 
most admirable means of checking the discharge, and obliterating the sac of the 
abscess. Upon this point the result of my experience is fully corroborated by 
that of Yelpeau. " Notwithstanding its unquestionable efficacy," he writes. 
" ; compression can. however, scarcely be employed at all in cases of pure and 
simple inflammation of the breast, nor in abscesses which are still closed. . . . 
It is more particularly where the pus has found an exit that compression is 
useful. After the opening of an abscess, more than any other method, it per- 
mits of our bringing the edges of the wound together, so as to promote its 
cicatrization, and by its assistance we sometimes succeed in completely curing 
the largest formation in the course of two or three days/' — Sydenham Society's 
Translation. 

Of the lacteal or lactiferous tumour, spoken of by Sir A. Cooper as occasion- 
ally forming in the breast after delivery, and requiring to be opened, I have not 
seen a single example, and on a very few occasions have I seen milk coming 
away in the discharge from an abscess. 

Only one example has fallen under my notice in which I felt satisfied the 
abscess of the breast was purely symptomatic. In this instance it succeeded to 
uterine phlebitis. An enormous swelling, attended with great pain, and some 
discoloration of the skin, formed in the upper part of the right mamma, extend- 
ing upwards to near the clavicle. On dissection, an immense quantity of un- 
healthy purulent fluid was infiltrated throughout all the structures of the part, 
and even permeated their tissues. In strict nosological nomenclature, then, 
this was a diffused symptomatic sub-mammary abscess. 

My remarks hitherto have been confined to cases of mammary inflammation 
and abscess subsequently to delivery. The same lesions may, however, affect 
the breast of the pregnant woman, and of such I have seen many examples 
occurring at the third month and upwards. 

Denman has shrewdly remarked that the state of pregnancy, though not 
exactly one of disease, yet borders very closely on it. This observation is 
applicable to every organ sympathetically or directly influenced by conception. 
The breasts, among others, become the seat of increased vascular and nervous 
activity, and hence a very trifling external injury is sufficient to induce serious 
inflammation. 



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Surgery. 



251 



When this arises spontaneously, we are to explain its occurrence, not by a 
retention of milk or obstruction of the lacteal ducts, but rather by supposing 
that the hyperaemic condition of the gland, which is a normal condition at this 
period, has gone too far — has exceeded the physiological limit, and merged into 
actual phlogosis. I cannot say that ante-part urn abscesses present any notable 
difference in their symptoms or course from those taking place post-partum, 
except that they are, perhaps, more frequently situated in the lobules of the 
gland. 

When allowed to burst of themselves, I have generally observed that they did 
so by two or more separate openings. If occurring towards the latter end of 
gestation, it may be found impossible to get the abscess to close till after de- 
livery. In cases of an earlier formation, the abscess has completely healed long 
before the setting in of labour, and, with a little extra caution, the woman has 
been able to suckle from that breast, though, generally speaking, a breast that 
has been the seat of inflammation and abscess, is more likely to be affected with 
the same again, on the occasion of next lactation. 

Dr. Johns thought that the Society was indebted to Dr. McClintock for 
bringing forward a paper so valuable as that just read. With respect to the 
use of the extract of belladonna in mammary abscesses, he had tried it frequently 
without any beneficial result. He found the lead lotion, applied warm, the most 
useful in those cases. He had seen lamentable consequences follow the employ- 
ment of cold lotions, and it was common practice amongst the poor to use cold 
vinegar. Leeches^were applied with advantage for the purpose of lessening 
pain, which was sometimes so severe as to keep the female awake at night. As 
to the time considered most desirable for opening the abscess, he should say 
that he was rather in favour of the early opening, because it prevented burrow- 
ing, and the healing took place more rapidly. Every practical surgeon had seen 
breasts become like a rabbit-burrow. He saw sinuses in every portion of the 
breast, and it was necessary to make a large sewer, as it were, in order to facilitate 
the healing process. An early opening, would, he conceived, have saved the pain 
and annoyance endured in the case to which he alluded. Then, as they were 
aware, the abscess was sometimes apt to burst through the nipple, and a large 
slough on the breast did not heal very quickly. Within the last month he had 
a case under his care in which he adopted the early opening, and about a small 
teacupful of matter was discharged. The discharge ceased in three clays ; and 
at the end of the fifth day the abscess was completely healed. After poulticing 
he found the spirit lotion, and also compression by sticking plaster, to act well 
in contracting the cavity. As soon as an abscess was formed, the occurrence 
of nodulated tumours was not unusual ; and he had seen great benefit derived 
from a liniment composed of iodide of potassium, with water of caustic potash 
— a scruple of the iodide to two of liquor potassse, and an ounce of olive or 
almond oil. — Dublin Medical Press, May 2, 1860. 

23. Injection of Iodine into the Peritoneum. — M. Boinet, in a paper on the 
differential diagnosis of abdominal tumours and ovarian cysts {Gazette Hebdom., 
Jan. 6, 1860), mentions a case in which he, by mistake, injected the iodized fluid 
intended for the radical cure of ovarian cysts into the peritoneum, with the effect 
of producing a radical cure of ascites, which, he states, had been confounded 
with ovarian dropsy. 

A young lady, of about thirty years of age, came to M. Boinet to be cured of 
an ovarian cyst, because she had heard of his iodine injections. She objected 
to an examination, because she had been well assured of the fact of her disease 
being ovarian by two eminent hospital physicians, and an appointment was 
accordingly made for the operation. Entirely trusting to the diagnosis of his 
learned confreres, the author, assisted by Dr. Delarue, and without even attempt- 
ing a verification of the previous diagnosis, made a puncture, and evacuated 
above twenty litres (forty-two pints) of serum. He then made the injection; 
but at the first introduction of the iodine the patient uttered so piercing a cry, 
and felt such intense pain, that M. Boinet at once felt assured that he had 
injected the peritoneal cavity. Universal purulent peritonitis resulted, placing 
the patient in imminent danger. Still, after much anxiety, and repeated punc- 



252 



Progress of the Medical Sciences. 



tures made for the purpose of evacuating the pus from the peritoneum, a radical 
cure followed. The patient is now (six years after the operation) enjoying ex- 
cellent health. 

24. CommunicdbiUty of Secondary Syphilis. — In a communication read be- 
fore the Harveian Society of London (May 17, 1860), Mr. "Weeden Cooke, 
said that it was singular how many questions respecting syphilis remained 
unsettled, considering the number who suffered from the disease, and the length 
of time it had been known and studied. Even the primary symptoms still give 
rise to controversy. Some declare the hard chancre only infectious ; others 
that the soft chancre does not infect the constitution, but may produce a hard 
chancre which does infect; while others denominate the soft chancre a chancroid 
ulcer which is not syphilitic at all. A fourth party considers both these chancres 
syphilitic, and therefore capable of producing constitutional symptoms. As a 
consequence of differences of opinion there is much diversity of treatment, which 
is a practical evil. Respecting the communic ability of secondary symptoms, 
there is much yet to be cleared up. It is a recognized fact, that secondary 
syphilis is conveyed through the father to the foetus in utero, and from the foetus 
to the mother. Mr. Cooke had verified this fact in numerous instances. He 
related the case of a lady who had two syphilitic children without herself being 
affected, but upon the birth of a third she exhibited all the signs of a severe 
constitutional attack. Although this mode of communication had been long 
recognized, it has until recently been denied that secondary symptoms ever were 
communicated from one person to another. It is well known, however, that M. 
Ricord, the staunch supporter of non-communicability, has been obliged to 
modify his opinions, owing to the production of incontestable evidence that the 
discharge from secondary ulcers did produce eruptions and ulcers of a similar 
character; while the French authorities, convinced of the possibility of this in- 
fection, not long since prosecuted two medical men for inoculating two children 
suffering from favus with the matter of secondary syphilitic disease. Mr. Henry 
Lee also has recently brought before the Profession instances which favour the 
conclusion that the constitutional disease can be conveyed from one person to 
another. Mr. Cooke then related the particulars of a boy who had recently been 
under his care at the Royal Free Hospital exhibiting indubitable evidence of 
this occurrence. A fine boy, seven years of age, was covered with an eruption 
which could not be mistaken for anything but psoriasis syphilitica. He had 
also enlargement of the occipital glands, the throat was injected, and recently, 
from being a very healthy boy, he had become cachectic. He was ordered two 
grains of gray powder twice a day, and got quite well in less than three weeks. 
His mother, who brought him, was herself afflicted with the same eruption. She 
had also ulcers on the inside of the lips and cheeks, and had suffered much from 
rheumatism. Her husband had given her primary syphilis one year before. 
After being " cured" of this, secondary syphilis appeared, and she was treated 
and got well. She remained well until about six weeks ago, and had since that 
time been affected as stated. The boy slept with his mother, and she was of 
course in the habit of kissing him. A month after the reappearance of the 
disease in the mother the son became affected. This case Mr. Cooke considered 
conclusive of the possibility of communicating secondary syphilis. It was no 
doubt a very rare occurrence, because the discharge from a secondary ulcer 
would very rarely be applied to a raw surface capable of absorbing it, but when 
so applied it evidently had the power of infecting a previously healthy person, 
and it was most desirable that this fact should be known and recognized. — Med. 
Times and Gaz., June 2, 1860. 

25. Condition of the Prostate in Old Age. — Dr. J. C. Messer, R. N., pre- 
sented to the Royal Med. and Chirurg. Soc. (May 8th, 1860), a report on this 
subject, founded on the dissection of 100 specimens in individuals over sixty 
years of age. In order to facilitate the consideration of the details of one hun- 
dred dissections of the prostate after the age of sixty, the author had arranged 
them into three classes, namely: First. Those under four drachms' weight; 
Second. Those between four drachms and six drachms' weight ; Third. Those 



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253 



over six drachms' weight. By so doing a broad division is at once made be- 
tween those that are comparatively healthy, namely, the first and second classes, 
and those that are so altered as to be likely to afi'ect the health of the patient, 
comprised in the third class. In the first class there are 20 cases, giving : — 

Minimum. Maximum. Medium. 

Age .... 60 94 76.2 

Weight ... 4 drs. 6 drs. 4 drs. 57 grs. 

These cases, for the most part, differed from the normal state only in point of 
size, and offered no obstruction to the flow of urine. The presence of small 
black concretions was very general in these as well as in all the other cases. In 
4 cases there were slight appearances of the formation of circumscribed tumours. 
In 1 case abscess was found associated with stricture of the urethra. In 1 the 
posterior lobe showed a tendency to enlargement ; but it was difficult to say 
whether the enlargement was more intimately connected with the prostate or 
with a fasciculus of the muscular coat of the bladder. In the second class are 
45 cased, which may be considered normal in condition, and which give : — 

Minimum. Maximum. Medium. 

Age .... 60 94 76.2 

Weight ... 4 drs. 6 drs. 4 drs. 55 grs. 

None of these cases suffered from urinary obstruction connected with the pros- 
tate during life, although the bladder was often found fasciculated. In 12 of 
these circumscribed tumours were observed, for the most part only slightly 
developed ; in 3 the posterior lobe was slightly enlarged ; in 1 abscess was pre- 
sent, the consequence of general paralysis. In the third class are 35 cases, 
which give : — 

Minimum. Maximum. Medium. 

Age .... 60 87 75.2 

Weight . . . 6 drs. 15 grs. 48 drs. 15 drs. 2 grs. 

In 17 of these the enlargement affected both lateral and posterior lobes ; in 14 
the enlargement existed chiefly in both lateral lobes ; in 1 the enlargement 
affected only the left lateral and posterior lobes ; in 1 enlargement preponderated 
in the left lateral and posterior lobes ; in 1 enlargement preponderated in the 
left lateral lobe ; in 1 enlargement preponderated in the posterior lobe. Thus 
it appears that 35 per cent, of all prostates after the age of 60 are abnormally 
large, 20 per cent, are abnormally small, and 45 per cent, are within the limits 
of the normal weight. This enlargement is principally caused by increase of the 
fibrous elements of the body ; the glandular also being increased in amount, but 
not to the same degree. This new fibrous tissue is deposited in concentric 
layers, and so forms circumscribed tumours. The frequency of this fibrous 
deposit is shown by the fact that it was present in 34 out of 35 cases of enlarge- 
ment, in 27 of which it was found in the form of tumours ; in 7 there was no 
appearance of tumours. It also appears that those glands in which the tumours 
are marked are liable to the greatest enlargement, as some thus affected were 
found to weigh 30 drs. and even 48 drs., while those in which the tumours did 
not appear never weighed more than 17 drs. A comparison of the relative fre- 
quency of enlargement of the different parts of the gland shows that the lateral 
lobes are much more liable to be affected than the posterior ; 34 of 35 cases 
were affected in their lateral lobes, while only 19 of the same number were 
affected in the posterior lobe. It is rare to find the posterior lobe enlarged 
while the rest of the gland is normal ; only 1 such case in 35 was found. En- 
largement of the posterior lobe is the chief cause of obstruction to the flow of 
urine ; but that may also be the consequence of hypertrophy of the lateral lobes, 
especially when it takes the form of tumours, and they project inwards upon the 
urethra. It appears from the nearly equal average age in all three classes, that 
the condition of the prostate does not materially affect the longevity of the indi- 
vidual. A slight difference does, however, exist in favour of those in whom the 
gland is most nearly normal, the average in these being 76.2, and in the enlarged 
75.2. The presence of abscess in the prostate produces enlargement to a 



254 



Progress op the Medical Sciences. 



[July 



greater or less extent, seldom, however, to the same extent as fibrous deposit. 
The most frequent cause of abscess in the prostate appears to be obstruction to 
the flow of urine, either from stricture of the urethra, enlargement of the pros- 
tate, or the consequence of paralysis of the bladder. The frequency of abscess 
in the enlarged gland is in the proportion of 5 in 35 ; in those between 4 drs. and 
and 6 drs., 1 in 45 ; in those under 4 drs., 1 in 20. The causes in these cases 
were — stricture of urethra in 3 cases ; frequent retention in 3 cases ; paralysis 
of bladder in 1 case. Tubercle is the only other abnormal deposit giving rise 
to enlargement of the prostate noticed in these cases, and that only in 1 case, 
which weighed 24 drs. A similar deposit was observed in the lungs, right kid- 
ney, and mucous coat of the bladder in this subject. It is worthy of remark 
that while retention of the urine, more or less complete, is the most important 
symptom and consequence of enlarged prostate, it is not found in every case. 
The proportion of men in advanced years suffering from the consequences of 
enlarged prostate is indeed small. Thus among 1600 old men, with an average 
sick list of 200, not more than 10 are under treatment for this disease, and half 
of these only occasionally. A much larger number must be affected with en- 
largement, as shown by post-mortem examinations of the gland. In 35 cases of 
enlargement found after death, 13 suffered no urinary symptoms during life, and 
2 others only after the occurrence of serious lesions to the nervous system 
shortly before death. Although many of these cases were not greatly enlarged, 
some of them plainly showed that the prostate may be greatly altered, and yet 
the patient be free from urinary obstructions, as in one case, where the prostate 
weighed 8 drs. 30 grs., with prominent enlargement of the posterior lobe ; in 
another, which weighed 19 drs. 30 grs., with general hypertrophy, and great 
encroachment on the urethra ; in another, which weighed 26 drs. 30 grs., with 
the enlargement principally seated in the lateral lobes. On considering the 
favourable circumstances for the formation of phosphatic calculi in cases of 
enlarged prostate, it is surprising that these concretions are not more frequently 
found. Of the 35 cases of the third class, phosphatic calculi were found in two, 
the largest weighing 7 drs. 45 grs. ; in another, two uric acid calculi, of about 
30 grs. each, were found. 

Mr. Henry Thompson said he had learned with great interest the result of 
Dr. Messer's careful and extended investigations. Having himself produced at 
this Society three years ago fifty prostates dissected by himself, he was ex- 
tremely anxious to compare his own results with the more recent ones of Dr. Mes- 
ser. He would briefly draw a comparison between them in relation to three or 
four points. First, the question of numerical frequency with which the enlarged 
prostate occurs among elderly men. Mr. Busk had been, perhaps, the first to 
question the received opinion that it was a natural result of old age. He (Mr. 
Thompson) had first applied the numerical method to the question. He found 
32 per cent, enlarged above fifty years of age ; Dr. Messer 35 per cent, above 
sixty. " Not above 12 per cent., however, showed symptoms during life. He did 
not consider that the 20 per cent, of prostates found by Dr. Messer, weighing- 
less than four drachms, were abnormally small ; true atrophy was much more 
rare than that. In reference to the seat of enlargement, he (Mr. Thompson) 
had published the result from an examination of 123 specimens ; the conditions 
found in Dr. Messer's 35 cases corresponded very closely indeed. The fre- 
quency with which fibrous tumours occurred in the enlarged prostate, was a 
subject to which he had drawn special attention. Dr. Messer had further 
investigated it, and had remarked the presence of these tumours in 27 out of his 
35 cases. The question of real incontinence, caused by enlarged prostate, was 
one which had been also carefully studied. It was well known that the so-called 
incontinence caused by enlarged prostate was almost invariably the overflowing 
surplus of a distended bladder, and indicated retention, not incapacity of the 
bladder to retain. Dr. Mercier, of Paris, had, in 1841, pointed out the fact that, 
by a peculiar formation of the enlargement, it occasionally happened that the 
neck of the bladder was rendered' patent, and the urine all ran off as fast as it 
was secreted. This was excessively rare, and he (Mr. Thompson) had not met 
with it among the numerous cases that he had examined ; but there appeared 
to be two cases among Dr. Messer's which corroborated the view referred to. 



I860.] 



Surgery. 



255 



He begged to thank the author for his valuable contributions to the subject 
under consideration. The confirmation of his own researches by this paper had 
been very remarkable. — Med. Times and Gaz., May 19, 1860. 

26. Enlarged Prostate. — Dr. Maclachlan exhibited to the Royal Med. and 
Chirurg. Soc, May 8th, three specimens of this. The first, which was that of 
a man 86 years of age, was the largest which had been met with in Chelsea Hos- 
pital for the last twenty years. The man had not suffered much, but occasion- 
ally was troubled with retention of urine. On these occasions it was generally 
easy to introduce an instrument, though sometimes there was difficulty — the 
catheter, no doubt, getting entangled in the transverse band, which was seen in 
the preparation, uniting the two lateral lobes, and also finding its way into a 
cul-de-sac, terminating the urethra in this specimen, immediately below where 
the so-called middle lobe usually exists. There was seldom impediment in mic- 
turition, notwithstanding the enormous size of the prostate, except when the man 
had been drinking, and then he invariably came intp the Hospital almost in a 
dying state. It was on one of these occasions that death took place. The second 
specimen was chiefly interesting, as it had been taken only a few days before from 
a man 73 years of age, who underwent the operation of puncture of the bladder 
about four years previously. There the obstruction arose from enlargement of 
the middle lobe, which was the size of an ordinary marble. The third specimen 
was taken from a case where it was also necessary to puncture the bladder, 
though the prostate was but of moderate dimensions. There was sometimes 
great difficulty in introducing a catheter, even where afterwards there seemed 
little to account for it : the parts then seemed to be altered from their usual 
position by the distension of the bladder and the enlargement of the parts, and 
one was much surprised, on subsequent examination, that the instrument should 
not have passed easily. He (Dr. Maclachlan) thought Dr. Messer's paper val- 
uable as confirming the opinion that so far from enlargement of the prostate 
being common in the old, it was the reverse — atrophy of the gland was the rule, 
and hypertrophy the exception. 

27. Tubercle of Bone. — Dr. Echeverria has brought forward in his thesis for 
the degree in medicine, some interesting points illustrative of the pathology of 
tubercle in the vertebra. The following are his conclusions : — 

1st. That the tuberculization of vertebrae, like that of other bones, is a totally 
different alteration from that of other organs. 

2d. That in bone, tuberculous infiltration never exists, that which is so called 
being of a nature differing essentially from tubercle of the encysted form, which 
is the only form in which it is found in bone. 

3d. The disappearance of the vertebrae takes place by resorption and inva- 
sion; occasionally a separation into fragments of the lamellae of spongy tissue 
exists, in which case the remainder depends upon the alteration alluded to, 
mechanical pressure having nothing to do with it. 

4th. The destruction of the vertebrae bears no relation to the abscesses found, 
which are more frequent when no gibbosity exists. 

5th. Deformity of the spinal canal generally occurs without obstruction. 
Thickening of the dura mater opposite the bend of the canal is the commonest 
cause of paralysis ; sequestra and products of alteration being less common 
causes. 

6th. The healing of tubercle of vertebrae occurs by means of a solid callus. 
The external callus is not worthy of the name, as it is only a consolidation from 
stalactites and bony projections. — Brit, and For. Med.-Chir. Rev., April, 1860. 

28. Results of A mputations observed at Constantinople during the Crimean 
War. — M. Salleron was in charge of the Dolma-Bagtche Hospital at Constan- 
tinople, which he represents as of faulty construction and deficient in hygienic 
appliances. Any mischief which would have resulted from these circumstances 
alone was augmented by the unavoidable overcrowding of its wards with the 
wounded soldiers. 

The immediate object of the author's paper is to give an account of the ampu- 



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Progress of the Medical Sciences. 



[July 



tations performed and treated under these painful circumstances, and especially 
to point out the greater amount of mortality that attended secondary amputa- 
tions. He selects the period from the 1st of May to the 1st of November, 1855, 
as being that during which the comparisons he desires to institute may be best 
made. During it, 2,753 gunshot-wounds were admitted, of which more than 
one-half were of a very severe character. Of the 2,753 patients, 2,009 were either 
discharged, or more often transferred to France for ulterior treatment, and 744 
died. After great engagements, the subjects of amputation were usually evacu- 
ated upon Constantinople as soon as possible, arriving there three or four days 
after the performance of the operations, with the stumps, as regards dressing, 
bandages, and cleanliness, in a most unsatisfactory condition. These operations 
and those performed in the trenches are entered in the hospital registers as 
immediate amputations, the secondary ones being those performed afterwards 
at the hospital itself. The bulk of these latter were also performed from five to 
ten days after the accident. The total number of amputations was 639 — i. e. 
490 amputations in continuity, and 149 disarticulations. Of the 639, 419 were 
primary operations, furnishing 221 recoveries and 198 deaths ; and 220 were 
secondary operations, furnishing 73 recoveries and 147 deaths. Thus, among 
the 639 cases there were 294 recoveries and 345 deaths, the primary operations 
yielding more than a half of cures, and the secondary operations yielding but a 
third. 

M. Salleron next examines into the immediate causes of this great mortality 
after amputation — a result so opposite to that which he and the other French 
surgeons had been accustomed to in Algeria, where amputations succeed very 
well. Omitting causes which only operated on a few cases, we find that of the 
345 deaths, 65 resulted from gangrene with emphysema, 45 from hospital gan- 
grene, and 228 from purulent infection. 

Gangrene with Emphysema. — The author met with gangrene under two forms 
— the oedematous or mild form, and what he terms the emphysematous or in- 
stantaneous form. No case of the former proved fatal, but rapid death occurred 
in 65 instances of the latter ; 46 of these had been amputations in continuity, 
and 19 disarticulations. Among 220 amputations performed in the hospital, 36 
cases of this form of gangrene occurred; while among 419 performed in the 
Crimea, only 29 cases occurred. Those about to be attacked seldom properly 
rallied after the operation, and were the subjects of great nervous irritation. 
The attack itself was quite sudden, the limb became rapidly and immensely dis- 
tended, and soon after blackened, the general symptoms undergoing frightful 
aggravation. It was not, indeed, peculiar to persons who had been operated 
upon, as it proved in some of those suffering from wounds rapidly fatal. The 
progress of the disease was always rapid and continuous, no kind of temporary 
suspension of its course ever being observed, and its mean duration in the 65 
cases was from twenty-five to thirty hours. The chief feature was an enormous 
emphysematous distension, which induced compression of the deep-seated veins. 
The superficial veins were distended with gaseous fluid, which also separated the 
fibres of the muscles from each other. These last were pale, but not disorganized. 
The patient always died, a state of indifference or stupor coming on, and all 
remedies proving useless. Perhaps the affection should rather be called emphy- 
sema of the stump than gangrene, for there was not the disorganization of tissues 
met with in ordinary gangrene ; on the contrary, they remained distinct and re- 
cognizable, and preserved their consistency, relations, and organization. 

Hospital Gangrene. — Besides the well-known ulcerative and pultaceous forms 
of the disease, the author met with a small number of examples of another form, 
hitherto unknown to him, and which he designates as caseous, which attacked 
stumps nearly healed. The lower angle of the stump became violaceous and 
engorged, and a small excavation formed, which soon filled with matter of a 
sebaceous consistency and of a grayish colour. This constantly increased in 
quantity as the excavation, which was lined by a soft membrane, rapidly aug- 
mented in size. The progress of the affection was at once arrested, while it yet 
seemed local in its operation, by the actual cautery or nitric acid. Hospital 
gangrene in the two other forms affected many patients besides those who had 
undergone amputation; and the author regards it as a manifestation of a general 



I860.] 



Ophthalmology. 



257 



pathological rather than a local condition, the air-passages being the ordinary 
vehicle of its transmission. He found local treatment of little or no avail, unless 
the overcrowding could be diminished and ventilation secured, which, under the 
circumstances, was rarely possible. Of the great number of local applications 
tried, the perchloride of 'iron succeeded best. In 30 cases, where all other treat- 
ment seemed unavailing, amputation was performed, 14 of the patients dying, 
and 16 recovering. In none of the 30 cases was there relapse of the gangrene, 
nor did one of them die of the immediate effects of the operation. 

Purulent Infection. — This prevailed in the Constantinople hospitals from the 
period of the battle of the Alma to the end of the campaign, and proved the 
principal cause of death after wounds and operations. It especially manifested 
itself in the case of osseous lesions, however slight these might be. Fractures 
of the shafts of the long bones were always rapidly followed by pyaemia, render- 
ing any subsequent operation useless and mischievous, inasmuch as this but 
accelerated the progress of the general affection, as of 490 amputations per- 
formed in continuity, 192 terminated fatally, while but 32 of 49 disarticulations 
exhibited a like issue. The author has found no description of treatment useful, 
and recommends only that symptoms should be combated as they manifest them- 
selves. — Brit, and For. Med.-Chir. Rev., April, 1860, from Recueil de Memoires 
de Medecine et de Chirurgie Militaires, torn. xxii. 



OPHTHALMOLOGY. 

29. Synthesis of Cataract. — Dr. S. Weir Mitchell, of this city, in performing 
some experiments on exosmosis, made the remarkable observation that, when 
syrup was injected into the subcuticular sacs of frogs, a curious form of cataract 
was produced. (See his paper in the number of this journal for January last, 
page 106 et seq.) 

.Dr. Eichardson, of London, after reading this paper, performed a number 
of experiments which confirm Dr. Mitchell's observations, and he brought before 
the Medical Society of London (March 26, 1860) animals presenting cataract in 
various stages. 

The leading facts adduced by Dr. Eichardson may be thus summed up : — 
" 1. When from one and a half to two drachms of syrup are injected under 
the skin of a frog, the body of the animal first becomes enlarged from exosmosis ; 
and afterwards, in from twelve to thirty-six hours (the enlargement having mean- 
while disappeared), cataract, usually in both eyes, is the result. This was con- 
firmed by twenty experiments, and is identical with the result previously obtained 
by Dr. Mitchell. 2. If the frog, after injection, is freely surrounded with water, 
it recovers without cataract, a fact observed also by Dr. Mitchell. 3. If, imme- 
diately after the lens becomes opaque, the animal is surrounded by water, the 
cataract may be made to disappear. This was confirmed by three experiments. 
4. The cataract, being fully developed, remains permanent ; the animal apparently 
recovering its general health, but being entirely blind. 5. When the cataractous 
lens is removed from the animal, the opacity may be seen to have commenced 
either at the posterior part of the lens, spreading circumferentially, or at the an- 
terior part, spreading backwards. The opacity is diffused, but it does not reach 
the centre of the lens. Similar observations had been made by Dr. Mitchell, 
except that he traced the opacity from the posterior surface in all cases. The 
capsule of the lens seems clear. {Mitchell.) A similar opacity of the lens may 
be produced in the eye of a sheep, immediately after death, by the injection of 
syrup into the anterior chamber. In these conclusions the results of both au- 
thors were in the main the same ; and, having described them, Dr. Eichardson 
referred to observations of his own. 6. All varieties of sugar — cane, grape, and 
milk — produce the same result ; and frogs were presented, with cataract induced 
by the injection of syrups of each of these sugars. 7. The form of cataract did 
not vary in any case. 8. After several experiments, it was found that a syrup 
No. LXXIX.— July 1860. 17 



258 



PROGRESS OF THE MEDICAL SCIENCES. 



[July 



of cane or grape-sugar, of specific gravity 1150, was the most practical; and of 
milk-sugar, that of specific gravity 1120. 9. Injection of gum-water does not 
produce cataract. In one case, after the injection of albumen, it was believed 
that some opacity was produced ; but a second experiment did not confirm this 
result. 10. Sugar-cataract is producible in other animals. In a fresh-water fish, 
placed in water brought to the specific gravity of 1070 by cane-sugar, perfect 
cataract was produced on one side, the other side seeming to escape altogether. 
A second fish, placed in the same solution, lived in it for several hours, but 
showed no cataract. In guinea-pigs, rabbits, and dogs attempts had been made 
to produce the sugar-cataract by injecting syrup into the peritoneum. Great 
difficulties, however, were experienced in these experiments ; for it was found 
that if an overdose of syrup was injected, the animal died rapidly, as from 
hemorrhage, through rapid transudation of water from the blood into the peri- 
toneal sac. If, again, small quantities were introduced, the sugar was rapidly 
eliminated by the urine ; in which it was found present, in one case, within an 
hour after the injection of grape-sugar syrup. But, by throwing an ounce of 
syrup of grape-sugar into the peritoneum of a rabbit, and repeating it after ten 
hours, distinct opacity of both lenses was produced. The animal, however, died 
after a third injection, the opacity increasing till death. The rabbit was pre- 
sented to the society. As to the cause of the cataractous condition, Dr. Rich- 
arclson considered it purely osmotic ; that is to say, it was due to an excessive 
transudation of water from the lens to the surrounding fluids, upon which the 
component parts of the lens were disarranged, and opacity was the result. This 
form of cataract, while it presented the appearances of common cataract, con- 
nected itself intimately with the facts which had been made out in the etiology 
of the disease, as to the coexistence of diabetes and cataract. Dr. Mitchell, at 
the conclusion of his paper, had noticed the same circumstance ; and Dr. Rich- 
ardson thought its importance could not be overestimated. The coexistence of 
diabetes and cataract had been pointed out by Mr. France, by Cohen, Lohmeyer, 
Gunzler, Mackenzie, and Duncan ; but especially by Yon Grafe, who had stated 
that, after examining a large number of diabetic patients in various hospitals, he 
had found about one-fourth of them affected with cataract. In Dr. Richardson's 
opinion, however, it was not necessary that the general manifestations of diabetes 
should always be presented for diagnosis when sugar existed in the secretions ; 
and it might be that there was such a condition as a temporary diabetic state, 
during which cataract might be developed. Any way, the synthesis of cataract 
by one process was demonstrated, and the first rational step towards the patho- 
logy of the disease had been made. As a point bearing on the treatment of 
cataract, Dr. Richardson said that inasmuch as temporary opacity produced by 
exposure of the lens to syrup was removable by an after exposure to water («. e. 
by changing the position of the medium surrounding the lens), it was worthy of 
consideration whether an operation for letting out the aqueous humour by a 
small opening, and refilling the anterior and posterior chambers with distilled 
water, might not lead to removal of the cataractous condition in the earliest 
stages. The author concluded with some complimentary remarks on the im- 
portant labours of his transatlantic brother, Dr. Mitchell." — British Medico! 
Journal, March 31, 1860. 

At a subsequent meeting of the same society (16th of April), Dr. Richardson 
made a second communication, in which he described a number of experiments 
made by him with various substances. 

" Glycerin. — Two experiments were performed with this. In the first, one 
drachm of glycerin being injected into the dorsal sac of a frog, there was pro- 
duced, in three hours, posterior opacity of the lens. In a second experiment, a 
drachm and a half was injected, which caused death in six hours, without 
cataract. 

"Alcohol. — A drachm of absolute alcohol, injected into the dorsal sac of a 
frog, caused death in two hours, with extraordinary shrinking of the body, and 
distinct double cataract posteriorly. Half a drachm of absolute alcohol, injected 
into the dorsal sac of another frog, caused death in six hours, with distinct cata- 
ract, but, singularly enough, on one side only. The cataractous condition pro- 
duced by glycerin and alcohol resembled that produced by sugars. 



I860.] 



Ophthalmology. 



259 



11 Chloride of Sodium. — By introducing into the dorsal sac of a frog from two 
to three drachms of a solution of chloride of sodium, of specific gravity 1150, 
the animal was rendered tetanic ; and in twenty minutes the limbs were drawn 
immovably towards the body, but jactitation of the muscles continued for an 
hour, when the animal died. Distinct cataract was produced in both lenses 
before death. In another experiment, a drachm and a half of the solution was 
used ; the same symptoms followed, but more slowly. Distinct cataract resulted. 
In a third case, one drachm of the same solution was injected ; death occurred 
in two hours, marked cataract having previously appeared. In a fourth case, 
half a drachm was used ; death occurred during the third hour, with the same 
signs of cataract. In a fifth case, one drachm of solution of chloride of sodium, 
of specific gravity 1050, was thrown in. In three hours there was distinct double 
cataract ; the animal was immensely shrunken, and the skin was dry, almost like 
parchment. Placed in water, the animal recovered ; and, the water being fre- 
quently changed, the cataract entirely disappeared in fifty-three hours. Cataract 
was reproduced in this animal, again removed, and again reproduced. Dr. Rich- 
ardson presented the animal with the cataract. The character of the cataract 
produced by chloride of sodium seems to differ materially from that produced 
by sugar. The lens is much firmer, and the opacity extends through the whole 
structure. The lens resembles one that has been boiled. 

'"Iodide of Potassium. — From the chemical analogy between chloride of so- 
dium and iodide of potassium, Dr. Richardson had used the latter salt in the 
same way ; the general symptoms produced were very similar, except that the 
cataractous condition did not result, at least so far as his experiments had gone. 

"Acid Urate of Soda. — From the fact of the insolubility of the urates, Dr. 
Richardson said that he did not expect that a cataract could be produced by 
the introduction of this substance into the blood. He did not conceive, that is 
to say, that any osmosis could be established by that salt ; but an accidental 
experiment had led him to try what could be done in this direction. On March 
2d of the present year he had commenced to administer to a well-fattened and 
healthy bitch the acid urate of soda, in doses of two drachms daily, with her 
food. His object was, to ascertain whether any affection of the joints would be 
produced. At this time she had taken nearly a pound of the urate, with no 
effect whatever on the joints ; but, within the last three weeks, with distinct and 
rapidly increasing indications of double cataract. The animal was exhibited to 
the society. Acting on this suggestion, the author had tried to produce the 
same effect on frogs, by charging them with the urate of soda, but without any 
similar result. The occurrence of cataract in the larger animal might therefore 
be a coincidence ; but Dr. Richardson was inclined to think that it was an indi- 
rect effect of the urate ; that is to say, he believed that the urate was decomposed 
in the digestive process, and changed probably into a lactate or other soluble 
salt of soda; which, being conveyed into the blood, produced the cataractous 
condition. In proof of this he showed that a solution of lactate of soda, of 
specific gravity 1060, produced cataract in frogs when injected. Dr. Richardson 
drew the following conclusions from the experiments : 1. In addition to the 
sugar-cataract, there is producible what may be called a saline cataract. 2. 
The appearances of the cataracts as produced by different solutions vary ; thus 
the cataract produced by chloride of sodium differs from that produced by grape- 
sugar. 3. The same cataractous appearance can be produced in a clear lens, 
after removal from the body, by immersion in solution of sugar, salines, etc. 
4. As the cataractous appearance is modified by the density of the producing 
body, and is removable by reversing the conditions which have led to it, and as 
it is producible in a clear lens removed from a body, it is a demonstration that 
the cataract induced in the different animals is a purely physical — that is to say, 
osmotic — change." — Ibid., April 21, 1860. 

30. Dislocation of the Lens, the Effect of Vomiting eight days after Kerato- 
nyxis. — The following case, related by Mr. White Cooper (Ophthalmic Hospital 
Reports, No. X.), is valuable as illustrating the importance of extracting the 
lens when it has been displaced and hence has become a source of irritation : — 

** On Tuesday, October 18, 1852, I operated with the needle on a congenital 



260 



Progress of the Medical Sciences. 



[July 



cataract in the left eye of Miss S., aged 20. The instrument was used lightly, 
and the capsule moderately lacerated at its centre ; the position of the lens was 
unaltered, and so little irritation followed, that at the expiration of a week the 
eye appeared to have recovered. 

" On the eighth day, however, she was attacked with obstruction of the bowels, 
attended with so much irritability of the stomach that for forty-eight hours every- 
thing was rejected by vomiting. It was not until after the administration of ten 
grains of calomel and repeated doses of purgative medicine that a passage 
through the bowels was obtained ; then an enormous quantity of offensive fecal 
matter came away. 

" On Thursday, the 27th, I was sent for, and found the eye in the following 
condition : The lens had been dislocated, and was pressing the iris forward, obli- 
terating the anterior chamber and partly filling the pupil, which was so widely 
dilated that the iris was reduced to a mere circular strip. The conjunctiva and 
sclerotica were acutely inflamed, and there was intense neuralgia of the branches 
of the fifth pair on that side of the head and face. 

" I at once proposed to place the patient under chloroform, and extract the 
lens ; but this proposition did not meet the approval of the patient or her rela- 
tives ; calomel and opium were therefore administered, leeches applied, and gene- 
ral antiphlogistic treatment adopted. Nevertheless, the inflammation became so 
acute, and the patient's sufferings so intense, that on the following Monday the 
required permission for the operation was granted. The patient having been 
chloroformed by Mr. Potter, I carefully made an incision with a broad iris knife 
through the cornea near the outer margin, and carried the point into the lens, 
which was broken up by a few movements of the instrument ; the knife was then 
somewhat turned on its axis, whereby the edges of the wound were separated, 
and the bulk of the lens was instantly expelled from the eye ; the remaining 
fragments were easily removed with a scoop. The lids were then closed, secured 
with plaster, and cold water dressings applied. 

"From this time the cessation of pain was complete; the patient, who had 
been five nights deprived of rest, slept profoundly more than ten hours ; the 
inflammation, which had been intense, speedily subsided under simple treatment, 
and at the expiration of a week scarcely a trace remained. The iris, however, 
continued paralyzed, and the pupils as widely dilated as when the lens was re- 
moved ; this state of things yet continues, and, according to my experience, 
many months may elapse before the activity of the iris is restored. With this 
exception, the eye is now (November 21) well, and the vision improving daily. 
With a three-inch lens large type can be read with facility. 

" This case forcibly illustrates the advantage arising from extraction of the 
crystalline lens when displaced, and causing irritation. Instead of the existing 
inflammation being aggravated by the wound inflicted on the eye, and the use of 
the scoop, there was from that time a diminution of all the symptoms ; and 
though it would have been better to have performed the operation when first 
suggested, as the iris would thereby have been relieved from the injurious 
pressure which for the time paralyzed it, the retina has fortunately received no 
injury, and a condition of mydriasis is the worst result which has followed the 
unfortunate displacement of the lens." 



MIDWIFERY. 

31. On the Use of the Forceps in Face Presentations. — Dr. Yon Helly, 
teacher of obstetrics in the University of Prague, presents a valuable analysis of 
the mechanism and treatment of face presentations. Starting from the familiar 
fact, that these are more tedious than labours in which the vertex presents, he 
says the reason lies in the circumference with which the head enters the pelvis, 
and in the unusual relations which the peculiar position of the foetus induces. 
The head of a foetus born by the vertex, is lengthened in the longest or diagonal 



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diameter, i. e., from chin to vertex ; the vertex is the highest point, towards 
which the roof of the skull forms a gradually inclined plane from the forehead. 
The diagonal diameter surpasses the straight one, from forehead to vertex, by 
an inch, so that the two diameters form two lines which, when the head is looked 
at in profile, form an irregular triangle. The occiput of a head born by face 
presentation appears drawn out or lengthened in the direction of the straight 
diameter ; the roof is but slightly arched, is flat, and ends in a sharper angle at 
the forehead. The difference between the straight and diagonal diameters dis- 
appears, so that the two lines, one drawn from forehead to vertex, the other 
from chin to vertex, form a nearly isosceles triangle. Measurements have been 
made in reference to this point in 32 cases ; these give : — 

The straight diameter was longer than the diagonal in 2 cases. 
" " equal to " 12 " 

\" shorter " 13 " 

*" " " 3 << 

1" " " 2 " 

The head finds, from the arching of the roof and occiput towards the opposing 
side of the pelvis, an obstruction to its descent, whence, through protracted 
uterine contractions, the neck is more stretched, the occiput approaches the 
back, and the forehead from having been the lowest part is drawn back. When 
the skull is flattened, and the head has in this manner lost in height, its vertical 
diameter decreases in length, and so finds room in the pelvic brim, the chin sink- 
ing backwards to be on same level as the forehead. When the face approaches 
the outlet, the chin immediately leaves the side of the pelvis, draws forward near 
the symphysis, and the neck places itself against the posterior surface of the 
anterior wall of the pelvis. Most frequently this change from the diagonal to 
the antero-posterior diameter is effected at the floor of the pelvis. The skull 
thus enters the cavity of the sacrum ; the chin is gradually driven forward under 
the symphysis pubis, and the face becomes visible between the labia pudendi. 
Forehead, roof, and occiput roll over the perineum, whilst the head, by revolving 
on its horizontal axis, is brought nearer to the breast. 

Dr. Yon Helly cites the well-known experience of L. J. Boer, as proving the 
efficacy of nature in bringing these cases to an end ; and says, that in 58 cases 
which have occurred in the last few years in the Prague Lying-in Hospital, per- 
foration was performed twice under urgent circumstances, the child being dead, 
and in two instances the forceps was used. 

Dr. Yon Helly deprecates attempts to alter the presentation by changing the 
face for the occiput, or by turning. In the 58 cases of the Prague Hospital 
there was a proportion of 18.19 per cent, of dead-born children, calculated in 
this wise : 2 were delivered after perforation, 1 was born putrid ; these three 
being subtracted, there remained 55 births. Of these 10 gave dead children 
The cause of this unfavourable result to the child lies in the compression which 
the skull and brain undergo ; in the obstruction to the circulation of the brain, 
caused by the diminution of the calibre of the vessels of the neck under the great 
stretching produced ; and, above all, by the long continuance of these dangerous 
conditions occasioned by the unusual protraction of the labour. Injury of the 
spinal marrow he looks upon as theoretical, and says he has found few opportu- 
nities of observing in the autopsies cerebral apoplexy, although there may be 
congestion of the brain and membranes. 

Before the dilatation of the os uteri, the author deprecates interference. In 
cases where the necessity for aid arises, and the os is open, the question, he says, 
is in what relation the forceps is to be applied to the face presentation, and how 
it is to be applied so as to entail no bad result for mother or child. The long 
forceps ought not to be applied when the head is still high ; at this stage the 
circumference and resistance of the head are still great ; the operation is very 
difficult, the prospect of the child's life very small ; whilst danger is incurred by 
the mother from the liability of the instrument to slip. Above the brim the 
double-curved forceps must be applied in the transverse diameter; one blade 
will lay on the forehead and crown, but the other can get no secure hold on the 
face and neck without so compressing the latter part as to destroy it. If urgent 



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circumstances call for delivery when the child is undoubtedly dead, perforation 
is to be resorted to. 

When auscultation declares that the child is alive, nothing but accidents 
threatening the mother can justify tentative applications of the forceps ; and as 
soon as conviction is obtained that further force is dangerous for the mother, 
perforation is indicated. The author agrees with Mittermaier and the greater 
number of obstetric practitioners in deciding in favour of perforation even when 
the child may still be alive, rather than with those who would wait until the 
lives of both mother and child are imperilled. But when the face has descended 
into the lower part of the pelvic cavity, the relations are so changed as to be 
more favourable for the forceps : one blade can be laid in opposition to the 
sacro-iliac synchondrosis, the other to the foramen ovale. If the chin be at the 
symphysis, the application of the forceps is of course still easier. 

The following two cases are important : — 

Case I. A woman who had borne eight children was in labour on the 9th of 
September at term ; the liquor amnii had escaped. Pains first came on next 
day, weak, and rare. Accustomed to quick labours, and getting anxious, she 
pressed the midwife to apply the forceps. This was done on the llth, and 
abandoned after fruitless attempts. Another and a third attempt was made on 
the following day by several physicians, which were equally fruitless ; and the 
patient was brought to hospital. The countenance was blanched, the features 
sunk, extremities cold, pulse scarcely felt, abdomen painful and meteoric, uterus 
unevenly distended, the lips of the os uteri swollen, hanging flaccid in the vagina. 
The head was in the brim, face presenting in the transverse diameter, the fore- 
head to the right and lower down. The presenting eye was hanging out of its 
socket; the epidermis came off the face in shreds. The patient was a little 
revived from her state of exhaustion by hot wine and musk. The trepan per- 
forator was applied, and a large putrid child extracted by forceps. On removing 
the placenta, the previously diagnosed rent in the uterus was felt. Death took 
place in the evening. Section revealed a rent in the fore and left side of the 
cervix, and a conjugate diameter of 3" 11"'. 

Case II. A woman who had borne four living children naturally was in labour 
at term. A surgeon called in, applied forceps an hour after escape of waters, 
and as this slipped, tried to turn. Flooding appeared, and the patient was 
brought to hospital. The pulse was small, quick ; abdomen distended with gas ; 
uterus contracted on its contents ; genitals swollen. In the vagina was the right 
foot and right arm. Higher up was felt the face on the brim. The head was 
prevented from descending by the lower extremities being dragged behind the 
head, whilst the descended arm was hemmed in between the head and the left 
side of the pelvis. The line of the face lay in transverse diameter, forehead to 
the right. The presenting arm was replaced with some difficulty, and so much 
room was gained that the forehead could be perforated by Kiwisch's instrument. 
The cephalotribe slipped off. By pulling at the foot extraction was at length 
effected. The foetus, apparently not long dead, weighed without brain 6f pounds 
Yienna civil weight. The mother collapsed after the operation, and died after 
four days under symptoms of peritonitis. Section revealed purulent exudation 
in great quantity, covering the peritoneum, and here and there between the 
lamellae blood-effusion. The iliac part of the peritoneum was torn through ; 
gangrenous endo-metritis ; left half of cervical canal torn through, the rent 
gaping, and opening into abdominal cavity. — B. and F. Med.-Chirurg. Review, 
April, 1860, from Vierteljahrschr., 1859. 

32. Experience in Face Presentations— Dr. Spaeth's experience in face pre- 
sentations may be usefully given in illustration of the foregoing. He found it 
occur seven times in 14,424 cases. At first the head is mostly in transverse 
direction, the greater fontanelle being to right or left. The further mechanism 
of labour always proceeded in like manner— namely, the head turned in the pelvic 
cavity with the face forwards, and at the outlet the upper lip was fixed against 
the symphysis ; the occiput then rolled over the perineum, when at last the 
mouth and chin emerged from under the symphysis. The configuration of the 
head was always the same, the forehead strongly projected forwards the sides 



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compressed unsymrrietrically, so that the side which was turned to the symphysis 
during- the passage through the brim appeared concave in the direction from 
above downwards. Of seven children, three only were saved ; in two cases per- 
foration was necessary — one was dead-born, one died quickly after birth. One 
mother died of metrophlebitis, which set in during labour. The rest recovered ; 
but three suffered from gangrenous ulceration, the result of the pressure during 
labour ; two of these suffered in addition from endo-metritis. 

The case should be left as long as possible to nature. If forceps become 
necessary whilst head is still high, it must be applied in transverse direction. 
When the case is complicated with moderate conjugate contraction, 3^ to 3^-", 
Spaeth advises delivery by turning. — Ibid., from (Est. Zeitschr. f. Prakt. Heil- 
kunde, 1859. 

33. Observations on External Turning. — Professor Carl Esteple gives an 
elaborate exposition of the subject of external turning. In some of the appli- 
cations of the operation his views and experience are extremely interesting. 
He commences by citing the opinions of Wigand, Matteo, and Stoltz ; and then 
considers the conditions which favour spontaneous evolution, and the manner of 
operating. The patient is to lay so as to relax the abdominal muscles as much 
as possible. The method pursued by nature in spontaneous version is to be 
closely followed. The partial peripheral contractions of the uterus which dimi- 
nish the transverse diameter are to be replaced by lateral compressions, which 
must gradually merge into a compressing stroke on one side near the fundus, on 
the other near the os uteri. This is much aided by gentle blows applied alter- 
nately to the apices of the ovum. These blows may be repeated more quickly 
at a later period by acting on the one side upon the head, whilst with the other 
hand a fixed point is maintained upon the opposite extremity. This will not 
always succeed in removing the head at the first attempt. When effected, the 
longitudinal position is to be maintained. This is to be done by the recumbent 
posture and bandages. The author's observations were made upon 500 pregnant 
women, who were mostly examined in the seventh and eighth months. Amongst 
these were detected 22 complete transverse presentations. Nine were rectified 
spontaneously; in 10 external turning was carried out ; in 2 turning by the head 
was effected by combined internal and external manipulations ; and in 1 case 
internal turning brought down the breech. In the 10 cases of external turning, 
placenta prsevia was present once ; pelvic contraction of the first degree twice ; 
excessive obliquity of the uterus three times. In some instances the cause of 
the cross-presentations was probably strong compression of the abdomen for 
the purpose of concealing pregnancy ; and perhaps also the weight of the 
clothes, which, as countrywomen wear them, presses almost entirely on the 
fundus uteri. 

We give three of his cases as examples of the practice : — 

Case I. A woman, pregnant thirty-four weeks ; head high to left ; back for- 
wards, breech towards right ilium, liquor amnii copious. It was sought to bring 
the head down, which was so far successful that it was brought within reach ; 
but as soon as the pressure was removed it receded. After two unsuccessful 
attempts to retain the head, the breech was brought down. This was effected 
without much difficulty, and was maintained. On repeated examinations, the 
longitudinal direction of the foetus, with the breech presenting, was constantly 
verified. Twelve days after the last examination labour began ; the occiput was 
presenting in first position, and the labour proceeded normally. 

Case II. Pregnancy near termination. Twins diagnosed ; one foetus in first 
head position, and one in cross-presentation, head to the left, back backwards. 
During la1»ur the first foetus had to be delivered by forceps. External turning 
was resorted to to rectify position of the second. The head was easily brought 
down, and whilst assistants by external pressure maintained it in situ, the mem- 
branes were ruptured, and the head was born in the first position. 

Case. III. A woman, pregnant thirty-two weeks. Head high to the right ; 
back backwards. External turning proved very difficult and tedious ; but by 
persevering especially with the methodical strokes, it succeeded in placing the 
head in the second position. Upon this the customary bandage was applied, 



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and recumbency on the right side prescribed. After a short time, however, the 
woman was unable to bear the bandage, or to lay in the position ordered. When 
examination was made four days after, the head had moved, but not quite back 
to its original place ; it had passed over to the opposite side, over the left crista 
iliaca. The causes of this side movement were the great quantity of liquor amnii, 
the great flaccidity of the uterine walls, and above all, a marked inclination of 
the uterus to the right, in consequence of which the breech, which had been 
brought to the fundus, continued to move in the direction of this inclination, 
and was supported by the laying on the right side, as ordered. External turning 
was performed a second time successfully. 

[The chief field for the useful application of this proceeding appears to con- 
sist in the rectification of cross-presentations during the latter weeks of gesta- 
tion. It is, of course, a substitute for the more severe and hazardous operation 
of internal turning. It deserves more attention than it appears to have received 
in this country. — Rep.] — Ibid., from Schmidt's Jahrb., 1859. 

34. Cases of Prolapsus of the Membranes in Labour. By Drs. Leopold and 
Crede. — Dr. Leopold was called to a woman who had been in labour for several 
hours, the midwife being puzzled by an unusual descent of the bag of membranes. 
A pyriform, tense, bluish bladder, six inches in length and two inches in breadth, 
projected from the genitals, the os uteri being expanded to the extent of one 
and a half inch only. As this prolapsus might give rise to separation of the 
placenta and spasmodic irritation of the os, the bag was punctured with a knit- 
ting-needle so as to allow of a gradual discharge of the waters, and leave the 
position of the child undisturbed, this having been ascertained to be normal. 
As it became emptied it gradually filled again, and was therefore cut away 
piece by piece with the scissors. The os uteri becoming more relaxed, the pains, 
which were feeble, were sought to be stimulated by ergot and external friction. 
The pains continuing feeble, and the child's mouth presenting, while a hand 
sometimes passed down beside it and some hemorrhage being present, turning 
was executed. The delivery was accomplished with some difficulty, but the child, 
at first stillborn, was speedily restored. 

Dr. Crede states that in his large practice he has only met with one case simi- 
lar to the above, and observes upon the fact of how little the circumstance has 
been alluded to in the text-books. In his own case, the bag consisted only of 
the amnios, which had passed through an aperture of the chorion (remaining 
above the os uteri), and constituted a longish, distended bag projecting five 
inches from the genitals. The case occurred in a primipara, and the presenta- 
tion was facial. The dilatation and presentation of the membranes proceeded 
regularly for awhile, when a little liquor amnii having become discharged, it was 
found that the chorion had burst. During the next pains, the amnios passed 
suddenly through the entire vagina, and projected five inches beyond the geni- 
tals. Passing the finger behind this bladder, its pedicle could be followed like 
a membranous cord into the pelvis. During the movements of the patient the 
bag burst, and its contents were discharged. The remains of the membranes 
which had constituted it, were ligatured with a red tape, in order to be able to 
trace their disposition afterwards. The amnios was found to have become com- 
pletely separated from the chorion, a circumstance very possible when there is 
a very loose gelatinous layer deposited between the two membranes, as was in 
this instance the case. The pains being very feeble, the labour was terminated 
by the forceps. — Med. T. and Gaz. Ap. 21, 1860, from Monatsschrift fur 
Geburtskunde, Bd. xiii. 

35. Twin Births. — Dr. E. Yon Siebold gives (Monatsschrift fiB Geburts- 
Jcunde, Bd. xiv.) an account of the twin births which have occurred at the 
Gottingen Midwifery Institution since its establishment. These amount to 89 
in number, occurring in 7139 births, which have taken place between the years 
1792 and 1859—^. e. 1 twin-birth in every 80 births. According to Yeit's sta- 
tistics, the proportion is in Prussia 1 in 89, in Wirtemburg 1 in 86, and in Sax- 
ony 1 in 78. In relation to different towns, great varieties in the proportion 
have been observed (as stated by Klirschner in his thesis), as 1 in 158 at Naples, 



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Midwifery. 



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1 in 126 at Palermo, 1 in 118 at Ltineburg, 1 in 110 at Marburg, 1 in 96 at Ham- 
burg, 1 in 88 at Berlin, 1 in 86 at Leipzic, 1 in 85 at London, 1 in 84 at Paris, 1 
in 74 at Yienna and Wiirzburg, 1 in 68 at Dresden, 1 in 62 at Heidelberg, 1 in 
72 at Prague, 1 in 75 at Philadelphia, 1 in 57 at Dublin. How rare is the occur- 
rence of triplets may be judged of from the statistical account of Prussia, given 
by Hoffmann, from which it appears that, between the years 1826-34, there 
occurred in Prussia 4,467,031 single births, 52,384 twin-births, 659 triplet cases, 
and 11 quartet cases. In the year 1840, too, there occurred 574,293 single 
births, 6381 twin births, 72 triplets, and 1 quartet. 

The author divides his analysis into two parts, the first comprising 35 twin- 
births, attended by Osiander between the years 1792 and 1822 ; and the second 
comprising 54 cases, attended by Mende and himself, between the years 1823 and 
1859. With respect to the first series of 35, the following positions of the chil- 
dren are indicated. In 19 cases the head presented in both children, in 6 the 
head and breech, in 4 the head and feet, and 2 the breech and feet. In one case 
the feet presented in both children, and in another case the breech presented in 
both. In one case, one child presented the head and the other the shoulder ; 
and in one case the position was not accurately ascertained. In the 35 cases, 
i. e. 70 children, only 28 children were delivered by leaving the case to nature, 
the others being removed either by the forceps, turning or extraction of the 
feet — meddlesome midwifery being strongly inculcated by Osiander in twin- 
cases, as affording the practitioner an admirable opportunity of practising 
midwifery operations ! The proportion of stillborn children is not stated. 

Of the second series of 54 twin-births, the following particulars are given. 
There were head presentations of both twins in 22 cases, head and breech in 11, 
head and feet in 10, head and shoulder in 5, breech in both in 2, breech and feet 
in two, the feet in 1, and the breech and shoulder in 1. Adding together the 
two series of cases, the following results are obtained : — 



Presentation of the head in both children . . . .41 

Head and breech 17 

Head and feet 14 

Head and shoulder 6 

Breech and feet 4 

Both breech presentations 3 

Both foot presentations 2 

Breech and shoulder 1 



88 

Of the 108 children born in the 54 twin-births, 83 were so by the sole efforts 
of Nature — interference by means of the forceps, by turning, or by extraction, 
only taking place with respect to 26 children — a marked contrast to the prac- 
tice pursued by Osiander. In 87 of the conjoined cases, 2 boys were born in 
28, 2 girls in 17, and a boy and a girl in 42 ; there being 99 boys and 77 girls 
in 178 children.— Med. Times and Gaz., May 5, 1860. 

36. On Special Position and the Obstetric Binder as Aids in the Treatment 
of Impeded Parturition. — Mr. Robert Hardey read before the Obstetrical So- 
ciety of London (March 7, 1860) a paper on this subject, in which he advocated 
the sedentary position on chairs, to which his attention had been first directed, 
in 1827, under the direction of the late R. M. Craven, Esq., Sr., of Hull. From 
that period to the present he had adopted this mode of management (and had 
recommended the same to his obstetric class at the Hull and East Riding School 
of Medicine) in all cases where the difficulties to be overcome demanded more 
than ordinary efforts for the accomplishment of the delivery. The author ob- 
served that in our treatment of labour generally we were apt to ignore the im- 
portant fact that the activities of parturition were dependent altogether on 
muscular power — ergo, all agents which sustained and increased motor force 
were real benefits to the parturient female, and vice versa. Of these excitors 
of motor power, two of the most valuable were the sedentery posture and obste- 
tric binder. Mr. Hardey next pointed out the advantages and disadvantages 



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resulting from a variety of parturient positions — viz., standing, reclining on the 
back, prone, and horizontal postures, and concluded this part of his subject by 
a strong recommendation of the sedentary posture on or between two chairs. 
The plan adopted was to secure the fronts of two chairs to each other, and sepa- 
rate their backs from one and a half to two feet ; to place the patient well over 
or between these, with her knees firmly pressed against the side of the bed, her 
chest fixed by holding on to the foot-post of the bed, and her feet placed firmly 
on the floor. The accoucheur sat or knelt behind his patient, who remained on 
the chairs till the difficulties in the case had been overcome, which was evidenced 
by the emerging of the ossa parietal from behind the perineum. The woman 
was to be then removed to bed, and finally delivered in the ordinary position. 
Before seating the patient, her abdomen was to be carefully sustained by a 
broad binder, to which Mr. Harcley attaches far greater importance than is 
conceded to it generally. The views advanced were illustrated by diagrams and 
drawings. In every case, before adopting the sedentary posture, the part pre- 
senting should be somewhat within the pelvis, and the os uteri half dilated. The 
practice was contra-indicated by — 1st, impending systematic exhaustion ; 2dly, 
inflammation in any vital organ or part more immediately associated with par- 
turition, serious uterine hemorrhage, previous puerperal convulsions, version 
presentations, a pulsating funis, and extreme pelvic obliquity. The agents 
named, the author maintained, secured to the parturient female in impeded 
labours — a, the very important aid derived from gravitation in the uterine 
ovum ; b, the putting forth under the most favourable circumstances the highest 
amount of motor energy of which nature is capable ; c, the bringing the abdo- 
minal and pelvic axes into the same obstetric plane; and d, the imparting great 
support to the fundis uteri in its contractions by the obstetric binder. He 
strongly recommended the use of the binder before delivery in a variety of cases, 
independent of its connection with the chairs, as an agent which usually acce- 
lerated the birth of the infant in a remarkable manner. The parturient condi- 
tions demanding the use of the chairs and binder were those arising from both 
mother and infant, in which unusual delay or difficulty presented themseives. 
The treatment of these was illustrated by cases, illustrative of the efficacy of 
the plans advocated. The period required for the delivery varied with the 
obstacles to be overcome, from one to two hours being ordinarily sufficient, 
with an interval of repose on the bed. In conclusion, Mr. Hardey commended 
the practice to his professional brethren from the following considerations : 1st, 
its great simplicity; 2dly, its entire freedom from danger per se ; 3dly, its very 
great potency ; 4thly, its testing the ability of nature to accomplish the delivery 
at a period sufficiently early to enable the accoucheur to decide on the use of 
instruments before material damage had been sustained by the maternal tissues ; 
5thly, the conscious satisfaction experienced by the woman at feeling her labour 
is progressing towards completion ; and, lastly, its being a great economist of 
professional time, which to medical men is property of the most valuable de- 
scription. 

Mr. H. impressed upon the meeting that he only recommended the sedentary 
posture in certain cases attended with difficulty, inasmuch as the ordinary posi- 
tion on the left side was admirably suited for the greater number of natural 
labours. — Med. Times and Gaz., March 17, 1860. 

37. Ruptured Perineum. — Mr. I. B. Brown related to the Obstetrical Society 
of London (May 2, 1860) a case of ruptured perineum, and birth of the child 
between the os vagina? and anus. In this case the child's head rested on the 
perineum, but delivery was delayed, though the pains were very violent, owing 
to the non-dilatation of the os vagina?. While a friend of the attending practi- 
tioner went to fetch the forceps, the perineum gave way between the os vagina? 
and anus, and the child was expelled completely through the opening. A fort- 
night afterwards Mr. Brown pared the edges of the wound, which remained un- 
healed, and cut through the fourchette. Iron-wire sutures were introduced, and 
the parts all healed completely. — Med. Times and Gaz., May 19th, 1860. 

38. Puerperal Convulsions successfully treated by Subcutaneous Injections 
of Morphia. — By Prof. Scanzoni, of Wurtzburg. Since the attention of the 



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Midwifery. 



267 



medical profession was first directed by Dr. Wood of Edinburgh, and more lately 
by Hunter and Behier, to the advantageous effects of subcutaneous injection, 
especially of narcotics, Professor Scanzoni has employed this method with suc- 
cess in numerous cases of neuralgia, hypersesthesia. etc. ; but he attaches especial 
importance to the following case of puerperal convulsions, because it seems to 
prove, in accordance with the views laid down by Hunter, that the subcutaneous 
application of narcotic agents furnishes a means of acting on abnormal irrita- 
tions of the brain with greater rapidity and certainty than the administration of 
the same remedies by the mouth. It will, doubtless, be admitted that opium, 
and its different preparations, deserve the first place in the treatment of puer- 
peral eclampsia. In his own experience, the observation of a large number of 
cases has convinced Professor Scanzoni that a kind of intoxication produced 
by opium leads with more certainty to a favourable termination than any other 
means recommended in this terrible disease. But. unfortunately, it is not always 
possible to administer a sufficient quantity of opium or morphia ; sometimes the 
comatose condition of the patient, at other times the rapid succession of parox- 
ysms, prevents administration by the mouth ; and opiate enemata are occasion- 
ally rejected as soon as they are received. The subcutaneous injection, however, 
supplies the means by which these difficulties may be overcome, and a sufficient 
quantity of opium introduced into the system to render its effects certain. Nu- 
merous experiments have convinced the author that, although the effect of this 
method is not always persistent (the neuralgise, for example, are not always 
cured by it), yet there are constantly produced, within a short time, often a few 
minutes, after the injection, certain phenomena, which can leave no doubt as to 
the action of the opium upon the brain. Such symptoms are drowsiness, giddi- 
ness, headache, sickness, feeling of constriction in the throat, even vomiting, and 
depression ; or, if the dose is large, somnolence. These facts, taken along with 
the known effects of the subcutaneous application in delirium tremens, mania, 
chorea, tetanus, etc.. induced him to try the same treatment in puerperal con- 
vulsions, and with the most satisfactory results. After three injections of me- 
conate of morphia there occurred only two attacks in nine hours, while pre- 
viously there had been three attacks in an hour and three quarters. This 
diminution of the convulsions after the injections is so much the more remarka- 
ble, since experience has shown that, as a general rule, the paroxysms become 
not only more violent, but follow at shorter intervals as the labour advances. 
And although the author does not imagine that he has discovered in the subcu- 
taneous injection an infallible panacea for this dreadful malady, he is of opinion 
that the following case should induce physicians to give this means a trial : — 

Case. — D., aged 21, primipara, strong and robust, was brought into the lying- 
in ward at a quarter to eight o'clock on the morning of June 8th, 1859. Labour 
had commenced in the night, and she had been seized with nervous paroxysms 
and loss of consciousness ; no account was given of the nature of the attacks ; 
the patient remembered nothing of what had occurred during the night. The 
whole body, and especially the lower extremities, were cedematous ; on the right 
side the tongue showed marks of being bitten by the teeth ; the uterus corre- 
sponded to the pit of the stomach, and seemed sufficiently consistent ; sounds of 
the fcetal heart distinct. On examination, the os uteri was dilated to the size 
of a sixpence, the bag of waters was partly formed, and the head presented ; 
the urine was very albuminous, and exhibited under the microscope numerous 
fibrinous cylinders. At eight o'clock she was seized with a second convulsive 
attack, which was of a very marked character, and lasted for some minutes. 
On recovering consciousness she could answer questions, although slowly. A 
third attack succeeded at a quarter to nine, a fourth at a quarter to ten, a fifth 
at a quarter to twelve, and a sixth at five o'clock — the last the most violent. 
After the fourth paroxysm consciousness did not return, and the breathing be- 
came stertorous. At ten o'clock she was bled to about eight ounces, an enema 
with 25 drops of laudanum was given, the body was put into a warm bath, while 
cold irrigation was applied to the head. As opium could not be administered 
internally, a solution of the meconate of morphia was now, at three different 
times, injected under the skin, the quantity amounting in all to about 10 grains 
(75 centigrammes) of opium. The labour advanced very slowly. At three 



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o'clock next morning the membranes burst ; the os dilated to the size of a half 
crown ; the head still high up above the brim ; sounds of the heart very distinct. 
After this period the dilatation went on more quickly ; at seven o'clock the os 
was larger than a crown piece, very extensible and dilatable, the head high up 
and immovable ; complete loss of consciousness, profound coma. In these cir- 
cumstances, which left little hope of saving the patient, and in spite of the high 
position of the head and the incomplete dilatation of the os uteri, it was decided 
to employ the forceps. Their application was by no means easy, but the ex- 
traction presented no difficulty. After a few tractions, a foetus was born, which 
breathed feebly at first, but soon began to moan vigorously ; the placenta fol- 
lowed. During the operation there was no paroxysm. Some wine and 10 drops 
of tincture of amber and musk were now given to the patient, which revived her 
a little, but did not restore consciousness. At eleven o'clock, a seventh attack 
came on, but was slight and short, after which she became excited, and tried to 
escape, but towards morning she grew calm. At nine in the morning she could 
answer questions put with a loud voice. During the whole day she remained 
like a drunken person ; pulse 128. The musk was stopped ; nothing but lemonade 
given. Towards evening the abdomen was somewhat painful. During the night 
there were several slight attacks of mania ; she constantly attempted to escape. 
In the morning she answered rationally; pulse 108. The oedema had diminished, 
the abdomen was still tender ; there was difficulty of breathing ; and numerous 
rales, fine and coarse, in the lungs. Warm bath, lemonade, expectorants, were 
prescribed. In the evening the patient was completely herself again ; pulse 132. 
June 11th and 12th. She slept well during the night, the expectoration becoming 
easy, and the pain of the abdomen relieved by fomentations and poultices : pulse 
120 ; the urine contained little albumen, and no fibrinous cylinders. June 13th. 
Good condition ; oedema gone, abdomen soft ; some incontinence of urine during 
the night was relieved by leaving in a catheter. All medicines were now sus- 
pended ; the patient was put on good diet ; and ordered to take every morning 
a glass of chalybeate mineral water. On the 17th there was no albumen found 
in the urine ; and on the 21st the patient left the hospital with her child, being 
advised to continue the use of steel for a considerable time. — Ed. Med. Journ., 
May, 1860, from Bull. Gen. de Thtrap., March, 1860. 

39. Morning Sickness ; its significance as a symptom. — Dr. T. Inman, of Liver- 
pool has published [British Medical Journal, 24 March, 1860) an interesting 
paper on this, sometimes, very troublesome affection. 

" All pregnant women," he remarks, " do not have the symptom in question ; 
many escape it entirely ; others have it at one time and not at another; some of 
those who escape it have flatulence and other signs of dyspepsia; others, simple 
faintness. If we dive still deeper, we find it common amongst town-bred women, 
and rare amongst the healthiest of the rural population, We find, as I have had 
repeated opportunities for observing, that a lady who suffers from it in a town 
is comfortable the day after she resides in the country, and is ill again the day 
after her return ; and that, for such a one, a prolonged residence in a pure air 
prevents morning sickness altogether. It is clear, then, that women are not 
sick simply because they are in the family way ; there is something required 
in addition to that, to produce the vomiting. 

" We next note that the sickness is most common in the morning ; but it is not 
generally present so long as the woman is lying down ; nor if the recumbent 
posture is continued, will it come on. But no sooner is the erect posture as- 
sumed, than nausea comes on, and increases until vomiting follows. Now, as 
we cannot see any material difference in the circulation through the stomach 
when a person is standing and lying down, we infer that we must carry our 
observation to some other part of the body likely to be influenced by change of 
posture. 

"A moment's consideration points us to the brain, as being the organ most 
affected by change of posture. A hundred cases occur to our recollection of 
faintness and sickness being produced in delicate individuals by assuming the 
erect posture ; and we also remember that vomiting is a common sign of ' water 
in the head.' But it is a tolerably certain fact that very few delicate people do 



I860.] 



Midwifery. 



269 



have morning sickness when they get up ; consequently, a change in the cere- 
bral circulation alone will not be sufficient to account for it. 

" We now attempt to get some farther insight into the causes which produce 
it, by examining under what circumstances it comes on in males, children, and 
elderly people. A gentleman, with his wife (who was not enceinte), when 
crossing the Atlantic, both had this symptom to a marked degree. During the 
day, they could stand the motion of the steamer pretty well ; they never could 
do so before breakfast. Champagne did more to relieve them than anything 
else. The sickness came on invariably, as soon as they attempted to stand up. 
Mr. W., aged 56, consulted a friend of mine for what he called dry vomiting. 
It came on regularly every morning as soon as he got up ; and he facetiously 
observed that, if he were a woman, people would say he was pregnant. 
The man was an habitual spirit-drinker, and indulged heavily over night ; and 
there was reason to believe that he had an ulcer in the stomach. A few days 
ago, I was consulted by a clergyman living in the country ; and one of the most 
prominent of the symptoms complained of was nausea as soon as he got out of 
bed, which was very frequently (twice or three times a week) accompanied by 
actual vomiting; and, as is common in pregnancy, a little mucus alone was 
ejected, and some flatus. In his case the disease seemed to be ulcer of the 
stomach, or atonic dyspepsia. Turning to Dr. Brinton's interesting treatise on 
this complaint, we find: 'Lastly, in those rarer instances in which the act of 
vomiting comes on quite independently of the ingestion of food, for example, 
shortly after rising from a night's sleep .... the vomiting, which is often 
periodic, is frequently connected with habitual drunkenness, especially with the 
collapse that follows a debauch' (p. 76). The clergyman was on his way to 
Southport when he consulted me, and he has subsequently called to say that the 
morning sickness has left him since his residence there. 

" We may next remark, as a matter of fact, that children and delicate people 
generally have anorexia in the morning, even if they have not vomiting ; and 
sometimes they are totally unable to eat anything at breakfast, from a feeling of 
faintness or sickliness. This is a tolerably sure indication of deficiency of diges- 
tive power in the stomach and in the body generally, and is best met by the use 
of some mild stomachic and fluid food. 

" When we inquire how much the condition of the uterus influences the vomit- 
ing, we find that the sickness is not produced by simple enlargement of the 
organ ; for it is not a common sign during the gradual distension that takes 
place from accumulation of the catamenia in cases of imperforate hymen ; nor 
is it from pressure in the pelvis, direct or indirect, for the symptom is generally 
absent from first to last in ovarian dropsy ; nor is the sickness produced by 
growths within the cavity of the uterus, for it is not a common sign in case of 
uterine polypus, etc. 

" We cannot laj much stress upon these facts ; yet we may remark, that morn- 
ing sickness accompanies the formation of moles, etc., which are supposed to be 
the result of an act of generation ; and that it also accompanies extra-uterine 
pregnancies, as far as we can judge from the few cases recorded, quite in the 
same proportion as the intra-uterine. 

" In the causation, then of morning sickness, we infer that ' uterine sympathy' 
does not hold so prominent a place as the formation of a new being. But neither 
the one nor the other hold sufficiently prominent a place to give to them the 
most important rank, inasmuch as neither one nor other produces the sickness, 
unless other conditions are president. 

" We ask, next, what these are ? As the symptom in question does not occur 
in perfectly healthy and strong women, we infer that its occurrence depends 
upon some deterioration of vital power. As deterioration of vital power involves, 
to a greater or less extent, deterioration in all organs of the body, we infer that, 
in the cases in question, there is deficiency of vital power in the brain, and in 
the stomach. 

" If this inference be true, we shall find that the best remedies for morning 
sickness will be those which improve the condition of the patient generally, those 
which improve the steadiness of circulation in the brain, those which improve 



270 Progress of the Medical Sciences. [July 

the tone of the stomach, those which deaden the sensibility of the organ which 
has been preternaturally increased by debility." 

With this view, Dr. Inman recommends that pregnant women " should take 
something' ere they get up, and allow sufficient time for this to have its influence 
on the stomach in dispelling flatus, on the circulation generally, and on the 
heart's power, enabling the latter to keep up the necessary volume of blood in 
the brain when the erect posture is assumed. I believe the best thing which 
can be adopted is a tumblerful of milk with a tablespoonfui of brandy or rum in 
it; it is food and stimulant combined. If this be objected to, hot coffee, cocoa, 
or tea will be of service, though all are too poor in quality to effect all we wish. 
Where the sickness is very distressing, champagne (or sparkling gooseberry) 
answers better than anything else. Throughout the day, everything in the way 
of work must be carefully noted, and its effects marked ; so that the patient may 
ascertain whether or not it is beyond her strength to do it. If the strength 
permit, exercise in the open air is useful up to a certain point, beyond that it 
fatigues, and makes the sickness worse. In bad cases, rest in bed is absolutely 
necessary for a time. Such tonics as steel, quinia, glycerine, and alcohol in 
medicinal doses, are each useful. Opium, from its influence on the brain and 
stomach, is specially advantageous. Of the special remedies I need scarcely 
speak, they are more or less familiar to all. 

'•The preceding observations go far to explain those curious cases we occa- 
sionally meet with where husbands suffer from morning sickness as well as their 
wives. I was once seriously consulted, by a recently married gentleman, for 
morning sickness. He wished to know whether it was usual for husbands to be 
affected sympathetically with their wives, and, if so, whether it was best to let 
it alone or try and prevent it. His own wife, he said, was pregnant, and suffered 
much pain from this symptom, and latterly he had suffered too. I ascertained 
that he was a man of nervously anxious temperament, unable to see suffering 
with equanimity; that he was passionately fond of his wife, and greatly dis- 
tressed at witnessing her morning suffering. Hence he became first faintish, 
and then sick. I recommended something for his wife, which had the desired 
effect; and when her suffering ceased, his sympathy being no longer roused, his 
stomach was quiet. Such an explanation, however, does not apply to an account 
I have received from a very trustworthy medical friend, who told me that a lady 
patient once told him in sober, serious earnest, that in two out of four pregnancies, 
she was first made acquainted with her condition, by her husband suffering from 
morning sickness, herself being quite free therefrom. There was no evidence to 
account for this curious state of things, and he could only surmise that the 
affair was accidental — due either to some temporary anxiety, casual marital 
excess, or some transient cause enfeebling the condition of the stomach." 

40. Pepsine in Vomiting of Pregnancy. — M. Corvisart recommends pepsine 
in the uncontrollable vomiting of pregnant women. M. Baudot relates (L' Union 
MM., April) two cases in which he employed it with the best effects, and M. 
Gentiles relates (Lancet, May 5th) one, a very severe and obstinate case, in 
which ten grain doses acted like a charm. 

41. Foetal Auscultation— -Dr. Francis Adams maintains (Med. Times and 
Gaz., Dec. 17, 1859), that the following points have been satisfactorily determined 
in regard to foetal auscultation : — 

"1. That the cases of spurious pregnancy related by Dr. Simpson, in which 
eminent auscultators fancied they could detect the double sounds of a fcetal 
heart when there was none present, and the various other instances of a similar 
character related above, all go to prove that this process of diagnosis is not at 
all to be relied upon as a test of pregnancy. 

" 2. That the leading facts of the case are so differently stated by different in- 
dividuals as to put it beyond doubt that these statements must have been much 
modified by previous impressions and modes of faith. 

" 3. That s.nce soufflets are often heard in the case of pelvic tumours, after 
delivery, and when the foetus is putrid and the placenta morbid, they cannot be 
regarded as placental nor as indicative of pregnancy at all. 



I860.] 



Medical Jurisprudence and Toxicology. 



" 4. That the sounds detected in the uterine region, unless double, cannot have 
been cardiac, nor unless double the arterial pulse of the foetus, can they have 
been connected with its heart, consequently that such an amount as from 140 to 
160 single sounds cannot be referred to the foetal heart. 

" 5. That one of the authorities for fcetal auscultation admits candidly that 
even this number of 140 double, or tic-tac, sounds is often not present in preg- 
nancy , and, on the other hand, that it is sometimes present when there is no 
foetus in utero. 

" 6. That the fcetal heart is so surrounded by a large mass of dense maternal 
structures and bloodvessels, and by the solid limbs and organs of the child, that 
it seems next to incredible that any sound emitted by it could ever reach the 
ear of an auscultator. 

" 7. That the whole system of foetal auscultation originated soon after the dawn 
of general auscultation, when men's minds were excited by the love of novelty, 
and warped by many erroneous impressions and mistaken modes of thinking, 
and has since been mainly upheld by authority." 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

42. On the Closure of the Anterior Fontanelle. — M. Roger observes that 
some of the commonest facts are those which are known with the least exacti- 
tude, and instances the contradictory statements made by the most eminent 
anatomists as to the period when the fontanelles close. He has himself ex- 
amined 300 children expressly to settle the point, and in this paper states the 
results. It is to be observed that he indicates the clinical and not the anato- 
mical closure, the former being considered to be present when the space is com- 
pletely filled up with matter as resisting as bone, and neither depression or 
cephalic souffle is perceptible. Actual bony union can only be proved by post- 
mortem examination. He gives the results of his examination of the 300 heads 
in detail, the general conclusion being that the period of closure is comprised 
between the age of fifteen months, when its occurrence is very rare, and the age 
of three and a half years, by which time it has always taken place. The usual 
period is between the second and third, year. The frequency of the occlusion 
regularly progressive from the twentieth to the twenty-third month, underwent 
a sudden increase after the second year, and went on increasing more and more 
to the third and a half year. Two affections may retard occlusion, rickets, and 
hydrocephalus ; and its non-occurrence may be one of the first manifestations, 
and afterwards a means of diagnosis, of the former of these affections ; while the 
persistence, extent, and especially the increase of the apertures at an age when 
they should have closed, are certain signs of hydrocephalus. Their premature 
occlusion, on the other hand, may give rise to a fear of the induction of compres- 
sion of the brain, and a, so to say, stifling of the intellect, i. e. a microcephalon 
or idiotcy. The rigorous determination of the period of the disappearance of 
the fontanelles may be of utility in legal medicine, in approximately establishing 
the age of a child or in a question of its identity. — Med. Times and Gaz., April 
21, 1860, from Union Med., 1859, No. 140. 

43. On the Linad Albicantes in Puerperal Women. — Dr. Crede was induced 
to prepare this paper by what he considers too indiscriminate a statement made 
by Casper, in his Handbook of Juridical Medicine. Casper states that the 
white lines or streaks of the abdomen are always present in women who have 
borne children, while women who do not exhibit them may be pronounced not 
to have had children. He states that he has never been deceived in his diag- 
nosis of delivery by their aid. This statement, from so high an authority, made 
in a book of large circulation, calls for, in Dr. Crede's estimation, a critical 
examination, and he lays down, as the result of his own observations, the follow- 
ing propositions : — 



212 



Progress of the Medical Sciences. 



[July 



1. These lines are formed in very different degrees in the majority of pregnant 
women, but are very seldom observed during the first half of pregnancy, and 
often only during the last or the penultimate month. During his management 
of the obstetrical department of the Berlin Charite, and at the Leipzig Obstet- 
rical School, Dr. Crede has paid particular attention to the matter, and the 
general result is that these white cicatrix-like lines have been observed in 90 
per cent, of the cases examined ; and they have very rarely ever been met with 
during the first half of pregnancy. They are usually disposed with some regu- 
larity, radiating from a mesial point that is placed about one or two inches 
below the umbilicus. With the expansion of the abdomen, the lines often 
become more irregular and unequal on the two sides. 

2. After delivery they put on another appearance, but do not entirely dis- 
appear. The freshly-produced streaks, especially in primiparse, are of a shining, 
bright, reddish appearance, in women having fair or red hair, and brownish in 
those whose hair is darker. The redness is lost sometimes only a few days after 
delivery, leaving a dirty white appearance, accompanied by wrinkling of the 
skin. On the occurrence of a new pregnancy, however, or when the abdomen 
becomes distended from any cause, the streaks exhibit a shining whiteness, with 
here and there a brownish tinge. 

3. In several instances no traces of these appearances are discernible, even 
after repeated pregnancies. The result of Dr. Crede's most careful examination 
went to show that these lines were absent in 10 per cent, of the cases he ex- 
amined expressly to ascertain the fact ; of these cases, 7^- per cent, were primi- 
parse, and 2^- per cent, multiparas. 

4. These streaks are sometimes formed only during the second or third 
pregnancy, or new ones may become added to those already existing. This 
may be owing to the greater distension the abdomen has undergone in subse- 
quent pregnancies. In general, it will be found that the woman in her first 
pregnancy was not strong, and had not carried her child to its full time. It is, 
at all events, common for a woman who has gone through a normal pregnancy 
without these lines appearing, to have them manifest themselves on subsequent 
occasions ; on the other hand, it is not uncommon for those who have aborted 
at the fifth or sixth month, to first exhibit them at the end of a subsequent 
pregnancy. That these marks, when once formed, ever disappear, Dr. Crede 
does not admit, and consequently he denies the correctness of the statement that 
they are met with more abundantly in primiparas than in multiparas. They are 
only more plainly seen on account of their brighter colour. 

5. The lines may also appear as a consequence of various diseases which give 
rise to great and sudden distension of the walls of the abdomen ; and this not 
only in aged women, but also in young persons who may very well become the 
subjects of juridical investigation. 

6. Lines of exactly a similar appearance which occur on the breasts, thighs, 
buttocks, or calves of the leg, equally deserve consideration with those observed 
upon the walls of the abdomen. Montgomery has especially dwelt upon the 
importance of the sign derived from the coincidence of the lines on the breasts 
and abdomen. Dr. Crede's observations have convinced him that their presence 
is of much seldomer occurrence on the breast and other parts named than on 
the abdomen. — Med. Times and Gaz., June 9, 1860, from Monatsschrift fur 
Geburtskunde, Bd. xiv. 

44. Condition of the Lungs after Death from Chloroform. — In an essay pub- 
lished in the Archives Generates (1858), M. Faure endeavoured to prove that 
when chloroform, in place of spreading equally and uniformly over the lungs, 
became concentrated at certain points during inhalation, such important modi- 
fications of the pulmonary tissue resulted as seriously to compromise the func- 
tions of respiration. The lungs then presented violaceous, or blackish spots 
which, on excision, proved to be deep-seated ecchymoses, having a greater 
extension within than externally. The tissue had lost all crepitation, becoming 
as if " felted," the blood no longer leaving it, but seeming to have become com- 
bined with it. It has been objected that such lesions were the result of the 



I860.] 



Medical Jurisprudence and Toxicology. 



2Y3 



mode in which the experiments were carried on, and that man, not breathing 
through tubes passed into the trachea, need not exhibit such appearances. 

A recent case, however, contradicts this view. A woman who had inhaled 
chloroform died suddenly, when to all appearances she was about to be saved : 
and the condition of her lungs was exhibited before the Paris Society of Surgery. 
The lungs, several portions of which were iu a normal condition, exhibited some 
singular congestions and ecchymoses. resembling those which M. Faure has 
described at great length, and having this remarkable, that they did not disap- 
pear even after the lung had been macerated for eight hours in water — the blood 
seeming, so to say, to have become combined with the pulmonary substance. The 
right lung was attached to the thorax by firm old adhesions, but the left lung was 
entirely free from these. The latter crepitated over nearly its entire extent, the 
non-crepitant portion being proportionally very small in extent, and emphyse- 
matous. The right lung crepitated nowhere, but was a very dense, fleshy, 
resisting mass, containing only a small quantity of air at its edges. Its colour 
was deep red or blackish at certain points ; this not resulting from hypostasis, 
for it was less deep where in that case it would have been most observed. The 
left lung was much less deeply coloured at points, but its general appearance 
was of a bright red. But the upper lobe of the left lung, i. e. just the point 
least. liable to cadaveric congestion, exhibited a considerable dense, deep-red 
congested portion, exactly like, indeed, the totality of the right lung. The 
heart was manifestly hypertrophied. 

Thus, in this case, the left lung had been in its normal condition, but the right 
lung was deprived of a portion of its functions — a circumstance which would 
become a source of danger when the subject' was submitted to the action of 
chloroform. It is certain that when a lung can no longer move freely in the 
pleura, its movements are diminished, and its circulation is more or less im- 
peded. Chloroform, in place of becoming distributed equably and uniformly, 
may then become accumulated in considerable quantity in a lung which can no 
longer return upon itself in consequence of the adhesions which affix it to the 
parietes of the thorax ; and lesions are produced resembling those which M. 
Faure determined artificially in animals — lesions which render the lung unsuited 
for hasmatosis and the continuance of life impossible. — Union 3l6d., 1859, No. 
144. 

45. Detection of Arsenic, Antimony, Copper, and Bismuth, by Electrolysis. 
— Prof. Bloxam, of King's College, has given the results of a very successful 
investigation of this subject, and showed that, by proper refinement in the 
method of operating, the process of electrolysis may become a certain and deli- 
cate means of detecting one or all of the metallic poisons, at least, with but few 
exceptions. In an examination for arsenic by this method, the metal is obtained 
in the form of arseniurettecl hydrogen ; the process is therefore very similar to 
that of Marsh, over'which, indeed, it does not present any advantage in point of 
delicacy. Marsh's process, however, although it is capable of doing all that can 
be done by electrolysis with even greater delicacy, is open to several well-known 
objections, which have stood in the way of its practical adoption by toxicolo- 
gists. The process of electrolysis does not involve the use of zinc, which is so 
difficult to obtain pure. It forms a general method for the detection of several 
metallic poisons at once, and the material tested is not destroyed or inconveni- 
ently contaminated, but may be used for another operation. \Vhen the arsenic, 
on the other hand, is present in a state of arsenic acid, it cannot, according to 
Prof. Bloxam's experiments, be detected with certainty by electrolysis. It is 
consequently necessary to reduce the arsenic acid by means of sulphurous acid. 
This is an objection which does not apply to Marsh's process. In his earlier 
experiments, Mr. Bloxam made use of a U tube containing dilute sulphuric acid ; 
the substance to be tested was introduced into one of the limbs, and a cork with 
a bent tube fitted to its mouth ; two platinum plates, leading from the poles of 
a battery containing five cells of Groves, were introduced into the two limbs, 
and the liberated hydrogen passed through the bent tube, which was heated by 
a lamp, when the arsenic, if present, was deposited. 

The form of apparatus ultimatelv adopted as being the most convenient, con- 
No. LXXIX— July I860.' 18 



214 Progress of the Medical Sciences. [July 

sists of a two or three ounce bottle, the bottom of which has been cut off, and 
replaced by a piece of vegetable parchment, bound on with platinum wire. To 
the mouth of the bottle is fitted a cork with a bent tube and a piece of platinum 
wire, which passes through the cork, and turns up beneath in the form of a hook. 
A slip of platinum then hooks in the end of the wire, and passes nearly to the 
bottom of the bottle ; it forms the negative pole of the arrangement. The bottle 
stands in an ordinary test-glass, and the positive pole, also of platinum, stands 
in the glass. Dilute sulphuric acid is put into the bottle, and also the glass, so 
as to stand to the same height in both vessels. The substance to be tested is 
introduced into the bottle, the cork adjusted, and the wires connected by five 
cells of Groves' battery ; the heat of a spirit lamp is applied to the bent tube, 
and in the course of a quarter of an hour a distinct mirror is obtained, if arsenic 
is present. Standard solutions, containing respectively a tenth, a hundredth, 
and a thousandth of a grain of arsenious acid, were prepared and examined by 
this process, and in every case a successful result was obtained. These solutions 
were then mixed with organic substances, such as the ordinary articles of food — 
meat, eggs, milk, &c. — and the resulting matter examined. 

It was got into solution by means of chlorate of potash and hydrochloric- acid, 
and the resulting fluid evaporated down by means of a water-bath to a thick, 
syrupy liquid. The arsenic was thus obtained in the state of arsenic acid, which 
does not give a certain result by the electrolytic process. Some sulphurous 
acid was therefore added, and the mixture introduced into the bottle, after 
expelling the excess of sulphurous acid by evaporation ; a drachm of alcohol 
was then poured over the surface, and the process put into operation. The 
author prefers to add this drachm of alcohol in every case, inasmuch as it not 
only allays the frothing, but also affords an additional indication of the presence 
of arsenic ; for when these two substances are present — the alcohol and the 
arsenic — the gas which escapes at the open end of the test tube possesses & very 
peculiar odour, resembling alkarsin. If a little sulphurous acid be present, it 
also furnishes an additional character indicative of arsenic ; namely, a slight 
yellow deposit, consisting of sulphide of arsenic, close to the borders of the 
metallic mirror. In all these experiments, of which a great number were made, 
the thousandth of a grain of arsenious acid was readily detected. 

The other metals which may be detected by this process are mercury, anti- 
mony, copper, and bismuth ; lead is precluded by the sulphuric acid which is 
present. These are all precipitated in the metallic form upon the slip of plati- 
num, and even in the case of antimony a mere trace of autimoniuretted hydrogen 
is formed, the metal being all deposited upon the negative pole. The mode of 
proceeding in these cases is precisely similar to that adopted for arsenic ; when 
the operation is concluded the slip of platinum is detached, washed, and the 
deposit dissolved off in the usual manner. Thus, where an organic mixture has 
to be examined for arsenic, mercury, copper, antimony, and bismuth, it is pre- 
pared in the manner just described for arsenic, and the resulting liquid intro- 
duced into the bottle, the drachm of alcohol poured over the surface of the 
contents, the cork adjusted, and the battery connected. The heat of a spirit 
lamp is applied to the bent tube, and the operation continued for about a quarter 
of an hour or twenty minutes, when, if arsenic is present, a metallic deposit, 
accompanied by some crystals of arsenious acid, will be formed in the tube, and 
the escaping gas will have the alkarsin-like odour. The piece of platinum in the 
bottle is next removed, washed, and boiled in yellow sulphide of ammonium. 
Antimony would be dissolved and might be obtained as sulphide by evaporating 
this solution to dryness. The other metals would still remain in the plate ; it is 
next boiled in nitric acid containing a trace of hydrochloric acid, the solution 
evaporated to a small bulk, and an excess of ammonia added. Oxide of bismuth 
would be precipitated, together with whatever traces of platinum had been dis- 
solved. The precipitate may be dissolved in hydrochloric acid, and tested by 
pouring into water, &c. The ammoniacal filtrate would contain the copper, 
indicated by its blue colour, and the mercury. By boiling with hydrochloric- 
acid and a slip of copper, the latter would be separated in the metallic form. — 
Pharmaceutical Journal, January, I860. 



I860.] 



215 



AMERICAN INTELLIGENCE. 

ORIGINAL COMMUNICATIONS. 

Case of Puerperal Convulsions from Albuminuria, in which Chloro- 
form ivas successfully used, with Remarks. By Cras. A. Lee, M. D. — 
Mrs. F. T., aged 21, of very small frame and feeble constitution, was taken 
with labour pains with her first child, May 4, 1860. She had for several 
weeks presented a very leuco-phlegmatic appearance, her face swollen and 
of almost an alabaster colour, feet and ankles also swollen, otherwise ap- 
parently healthy, although troubled more or less with headache. She was 
able to take exercise, and the day before she was confined she walked nearly 
a mile. On examining the urine it was excessively loaded with albumen, 
containing by far the largest amount I have ever found in any case what- 
ever. Fearing convulsions, I had procured a quantity of pure chloroform, 
of Squibb's manufacture, and used it in moderation for three hours before 
delivery, and giving it during the few last pains to the extent of producing 
complete unconsciousness. Labour pains commenced at 1 o'clock A. M., 
and delivery took place at 3 P. M. It was given throughout in quantity 
sufficient to produce perfect tranquillity, applying it as soon as the first 
indications of a pain were perceived, and withdrawing it when over. 

Several times before the labour was completed, there were indications 
of approaching convulsions, such as turning up of the eyes, contractions 
of the hands, and involuntary twitchings, which were at once removed 
by the inhalation of a small quantity of chloroform. There was but very 
slight discharge of blood on delivery of the after-birth, certainly not more 
than four ounces altogether ; the placenta having been spontaneously de- 
tached, was removed about half an hour after the child was born. The 
patient, on awaking a few minutes after the expulsion of the child, was 
surprised and gratified to find that all was over, and expressed herself as 
perfectly comfortable. After remaining about an hour, I left to visit some 
other patients, and on my return in an hour and a half after, found that 
she had had two very violent convulsions ; the first about half an hour after 
I left the house. It came on suddenly, without any warning or premoni- 
tory symptoms whatever, and lasted two or three minutes. Soon after 
entering the room another very severe convulsion occurred, which was fol- 
lowed in an hour by another, and in the course of the next twelve hours as 
many as ten more. Having employed the usual means, with the exception 
of bleeding, general or local, and the fits increasing in severity and fre- 
quency, I procured a quantity of pure chloroform, and stationed myself at 
the bed-side, which I scarcely left for the next forty-eight hours. The 
patient, I should have stated at first, retained her consciousness between 
the fits, but latterly remained perfectly comatose, and could not be roused. 
The convulsions were of an epileptiform character. During the attack the 
face was distorted by spasmodic contractions, the pupils dilated, the eyes 
agitated and turned upwards, the tongue protruded, and the under jaw 
closed with such violence that the tongue was badly bitten before any pre- 
cautionary measures were taken, all the muscles of the body seemed thrown 
into violent and irregular action, the limbs jerked in all directions, and it 



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seemed as if every joint would undergo dislocation. The expiration was 
irregular, the pulse very frequent and feeble. The paroxysms fortunately 
were not of long duration, the longest not exceeding five minutes. 

After commencing the use of the chloroform but one paroxysm occurred, 
and that was during my absence from the bedside. About half a minute 
before the convulsion began, some premonitory symptoms appeared, such as 
turning up of the eyes, grasping or contraction of the hand and fingers, 
closing of the teeth, and slight general agitation. As soon as any of these 
symptoms appeared, about a drachm of chloroform was applied to the 
mouth and nose on a handkerchief, and two or three inspirations were 
enough to cause entire relaxation, and a removal of all the threatening 
symptoms. The control exercised by the chloroform over the morbid con- 
dition, or exciting cause of the paroxysms, was perfect and complete ; nor 
was the pulse rendered more frequent or feeble in consequence of its use. 
The vital functions were all carried on with regularity. Its use was dis- 
continued as soon as the threatening symptoms above mentioned disap- 
peared, which was about forty-eight hours after delivery. On examining 
the urine at the end of that time, it was found to be free from albumen. 

The patient remained wholly unconscious all this time, and for nearly as 
long a period afterwards. The pulse most of the time ranged from 150 to 
180 in a minute, much of the time too feeble and frequent to be counted ; 
it, however, gradually came down, so that by the fifth day after delivery it 
was but 120. Life was sustained by giving essence of beef, brandy, carb. 
ammonia, wine, &c, at regular intervals. It is now twenty-two days since 
her confinement, and she is progressing as favourably as could be desired ; 
sitting up a good part of the day and nursing her infant, which has gained 
two pounds since birth. In all, about fifteen ounces of chloroform were 
used. 

Remarks. — ~No reasonable person, I think, can doubt for an instant that 
chloroform was the means of saving life in the instance above related; after 
all other means had entirely failed, life nearly extinct, the paroxysms be- 
coming more and more frequent, and all hope of saving the patient nearly 
abandoned, the anaesthetic powers of chloroform were called into requisition, 
and with absolute and perfect success. It seemed to be the agent expressly 
made for just such an emergency ; for it met most fully and satisfactorily 
all the indications of the case, and rescued the patient from the very jaws 
of death. There is every reason to believe that it prevented an attack of 
convulsions before parturition was completed. There were all the premoni- 
tory symptoms of a paroxysm present, the same as preceded the fits after 
delivery ; but on the prompt use of chloroform they instantly disappeared : 
and this fact, taken in connection with its effects in other similar cases, 
makes me doubt very much the propriety of the rule laid down by Professor 
Henry Miller, of Louisville ( The Principles and Practice of Obstetrics, 
Philada., 1858, p. 518), in such cases, as follows : — 

" From the very nature of the disease, and the circumstances in which its at- 
tack is made, we should expect that there can be no security for the mother 
except by delivery, originating in the peculiar condition of the womb during par- 
turition, nothing but a total change of this condition, such as delivery brings 
about, can be expected to put a stop to the convulsive paroxysms. 

" With every returning uterine contraction, the equilibrium of the circulation 
is disturbed, and irritation is propagated anew, from the cervical nerves to the 
true spinal system, and thus the disease must be kept up, in spite of all the re- 
sources of ordinary therapeutics. This is, in effect, admitted, by the most san- 
guine advocates of the lancet, even by Gooch and Dewees, who advise delivery 



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Original Communications. 



by the forceps, as soon as it is practicable, now, I go a step further and contend 
that, where the mother is placed in the fearful jeopardy supposed in the outset 
of these remarks, it is lawful, nay, it is our imperative duty, to deliver by cra- 
niotomy, whether we have complete assurance of the death of the child or not." 

In the first place, it may be remarked that it is an entire assumption, un- 
supported by any known facts, that the cause of puerperal convulsions con- 
sist "in a peculiar condition of the womb during parturition." There is 
no subject in regard to which greater discrepancy of opinion exists than 
that of the remote and proximate causes of puerperal convulsions. Scarcely 
any two writers have expressed the same opinions. A very common opinion 
among medical men is, that the principal exciting cause is congestion of 
the cerebral vessels, or pressure on the brain, while Dr. Collins thinks we 
are quite ignorant as yet of what the cause may be. ( Treat, on Midwifery.) 

Puerperal, like all other convulsions, may be centric or eccentric, and the 
stimulus mechanical or emotional. The centric causes may be intra-verte- 
bral, or intra-cranial, or both. Pressure on the brain from fulness of the 
vessels, a clot of blood, or collection of serum, may, by counter pressure on 
the medulla oblongata, cause convulsions. So also, similar causes acting 
on the spinal meninges, and medulla, produce the same effect. In like man- 
ner, an opposite condition, a want of a proper supply of blood to these 
central organs of the nervous system, will cause convulsions ; as we see in 
cases of fatal uterine hemorrhage, or in animals bled to death. But the 
most important and most frequent of all these causes, Is the constitution of 
the blood. This fluid becomes changed from its normal condition, during 
utero-gestation, by the imperfect depurating action of the secretory and 
excretory organs, caused chiefly by want of proper exercise, and the me- 
chanical pressure of the gravid uterus on the intestines, the renal vessels 
and nerves, and the kidneys. The blood, moreover, does not undergo tho- 
rough oxygenation, from the pressure upward, preventing the free action 
of the diaphragm. But chiefly does the blood become a morbid stimulant 
to the spinal system, in consequence of the loss of albumen by the urine 
and the retention of the urea and other salts in the blood, causing the now 
well known affection albuminuria, we have no accurate statistics, showing 
the proportion of cases of convulsion dependent upon this condition of the 
blood, but it is very safe to say, that in a vast majority, especially of primi- 
para, it is the exciting cause. Thus, Dr. Lever remarks, "I have carefully 
examined the urine in every case of puerperal convulsions that has since 
come under my notice, both in the Lying-in Charity of Guy's Hospital and 
in private practice, and in every case but one the urine has been found al- 
buminous at the time of convulsions. I further have investigated the condi- 
tion of the urine in upwards of fifty women, from whom the secretion has 
been drawn during labour by the catheter ; great care being taken that none 
of the vaginal discharges were mixed with the fluid ; and the result has 
been, that in no cases have I detected albumen except in those in which 
there have been convulsions, or in which symptoms have presented them- 
selves, which are readily recognized as precursors of puerperal fits," and "this 
has been confirmed by numerous writers on this subject, as Simpson, Le- 
groux, Blot, and others." That the mechanical pressure upon the kidneys, 
by causing congestion of these organs, is the cause of albuminous urine, can 
scarcely admit of doubt, inasmuch as this condition is met with most fre- 
quently in primipara, and disappears in two or three days at furthest after 
parturition. There is no evidence whatever to show that it is dependent 
in such cases on granular degeneration as has been maintained by some. 



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It is evident, that the depuratory actions of the kidneys should be active 
during the puerperal state, in order to eliminate the debris of the foetal 
and maternal system, and thus preserve the health of the mother. It is 
no less evident that the causes already mentioned, tend to impair the ex- 
cretory functions, and produce that condition of the circulating fluids, as to 
predispose to, or excite convulsive action. In regarding the state of the 
blood circulating in the spinal centre, as the most frequent cause of puer- 
peral convulsion, we do not deny the influence of eccentric or reflex 
causes in certain cases, such as irritation of the uterus itself, and the uterine 
passages ; irritation of intra-cranial excitor nerves ; irritation of the ova- 
ries ; of the intestinal canal, the stomach, the bladder, and possibly the cu- 
taneous nerves, though several of these causes may act together, and centric 
and eccentric causes be combined in producing the result. In some cases, 
it may be difficult to decide which are the remote and which the exciting 
causes ; or, whether the same cause may not be both predisposing and ex- 
citing. But in either case, I believe it will be found that chloroform is, in 
a vast majority of cases, the sheet anchor of our reliance. 

In the case which I have briefly sketched, the prognosis was nearly hope- 
less. The patient was of very feeble constitution, very slight frame, a 
highly nervous temperament, the urine loaded with albumen, and she had 
lost a brother of the age of 14, a few months previously, of albuminuria. 
I am fully aware that, in a general rule, it would not be safe to rely on a 
single case for guidance in the management of this dangerous affection, but 
I was too much gratified with the action of chloroform in this case, and I 
think it well worthy of being communicated. 

Case of Poisoning by Strychnia; Use of Chloroform. By J. R. 
Smith, St. Mary's, Co. of Perth. — In November, 1857, I was called to see 
a young man by the name of Daniel Reardon, in this place, who, it was 
supposed, had been frozen. Upon examination, I discovered the symptoms 
of poisoning by strychnia. The muscles were powerfully contracted, the 
limbs stiffened, the jaws locked, difficult respiration, pulse small and fre- 
quent ; from the severity of the symptoms I did not think it possible for 
the man to recover. The first remedy, which suggested itself as the best, 
was chloroform, which I administered by inhalation sufficiently to relax the 
muscles to admit of easy flexion of the legs and arms ; respir